Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 South Dallas Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to supervise a resident with dementia and fluctuating cognition allowed her to leave the building without signing out and remain missing for about 24 hours. Staff gave conflicting accounts about whether she could leave on her own, while records showed she was not on the approved sign-out list at the time of review and her care plan did not identify special supervision or unsupervised pass privileges. The resident later said she did not remember leaving and did not tell staff because she did not want them to know.
Surveyors found that the facility did not maintain a clean, safe, and well-kept environment in several halls, common areas, and a resident room. Exit doors on multiple halls had accumulated dark dirt and leaves, and the dining room flooring near the kitchen and ice machine was torn. In one room, an A/C unit was loose and gapping from the wall with visible gunk and matted black dirt, a hole in the adjacent wall, and a toilet missing its tank cover. Staff interviews showed that while all staff were expected to report environmental and maintenance issues, housekeeping coverage was inconsistent, some areas were not being routinely cleaned, and needed repairs were not identified or reported in a timely manner.
Surveyors found unsanitary kitchen conditions, including an uncovered floor drain near the dishwashing area, a non-operational sink covered with a plastic bag from which a rodent was seen exiting, and about 30 gnats swarming over plates and old food on a tray rack. A large rat trap with a small food scooper was stored on the bottom rack of a food prep table. Dietary staff present during the rodent sighting declined to be interviewed. The DM reported a history of pest and rodent activity, frequent sink backups with standing water that contributed to gnat multiplication, and acknowledged that these conditions were unsanitary. Leadership staff, including the ADON, DON, MHS, and ADM, reported no known resident complaints or illnesses related to food or pests, but recognized that such infestations and conditions could make residents sick. Pest control records showed recent capture of multiple rats and mice in the kitchen and treatment for fruit flies and other insects, despite a facility sanitation policy requiring the kitchen to be kept clean and protected from pests.
The facility failed to maintain an effective pest control program, as evidenced by multiple resident and staff observations of rodents in resident rooms and hallways and surveyor observations of gnats and a rodent in the kitchen. An anonymous resident had video evidence of a rodent near his bed and reported seeing rodents on multiple occasions without reporting them, while another resident reported a rodent emerging from his closet. A CNA reported a hallway rodent and the use of glue traps, and the Business Office Manager reported a rodent entering the front office and moving down the hallway. Despite these events, the grievance log contained no pest-related entries, and several staff, including the ADON, SW, and DON, stated they had not observed rodents or insects or received resident reports, even as pest control contractor records documented repeated captures of mice and rats, treatment for fruit flies, and structural issues that could allow pest entry. The facility’s own pest control policy required an ongoing program to keep the building free of insects and rodents, but the documented rodent and insect activity in resident and kitchen areas showed that this program was not effectively implemented.
Surveyors found that one of two oxygen cylinders stored next to a crash cart behind a nurse’s station was not secured in a rack, contrary to NFPA 99 requirements that freestanding cylinders be properly chained or supported. An LVN acknowledged the tank was unsecured, stated she had just started her shift and had not noticed it, and confirmed it should always be secured because it was a hazard and could cause a fire. The DON reported she was unaware the tank was unsecured, indicated that night shift staff were responsible for checking crash carts and may have changed out the tank and failed to return it to the storage room, and stated her expectation that oxygen tanks be secured at all times, while also noting the facility lacked a policy on oxygen storage.
Delayed Weekend Mail Distribution: The facility failed to ensure residents received mail on Saturdays and that their communications were handled as required. In a confidential resident group, all members stated they never got mail on Saturdays because the Business Office did not work then, even though a receptionist was present. Interviews showed mail was dropped at the front desk, but it was not being passed out over the weekend as expected.
Failure to maintain required RN coverage: the facility did not use an RN for at least 8 consecutive hours a day, 7 days a week on numerous reviewed dates. The DON stated she was the only RN, had no RN weekend coverage, and could not provide 8-hour daily coverage; the Administrator confirmed the DON was the only RN, weekends were covered by LVNs, and agency RN staffing was not used. PBJ staffing data showed no RN hours for multiple quarters, and the facility’s staffing policy required sufficient nursing staff based on resident needs.
Improper food labeling and dating in kitchen storage. Surveyors observed multiple dry goods bins and opened pantry items without proper labels, item identification, or use-by dates. The kitchen storage area had bins of rice, flour, breadcrumbs, potatoes, and beans with incomplete dating, and the dry storage area had opened tortillas and puree rice without full labeling. The weekend cook said food was already put away when she arrived, the Dietary Manager said opened packages should be labeled, and the Administrator was unaware the items were not meeting labeling requirements.
PASRR screening and assessment submission failures were identified for two residents. One resident had a PASRR Level I screening that was not updated after a later bipolar dx, despite records showing dementia, psychotic disorder, PTSD, and bipolar disorder. Another resident with Duchenne or [NAME] muscular dystrophy, dementia, and major depressive disorder did not have the required PT, OT, and ST assessments submitted within the PASRR deadline after selecting services, causing the process to be delayed.
Expired insulin was found in the med room refrigerator for a resident with DM and cognitive impairment, and staff identified that the insulin had exceeded the 28-day beyond-use period after opening. In addition, an LPN and an MA were observed placing personal beverages on medication carts during med pass, which they acknowledged should not occur because of cross contamination and possible medication mix-up.
Hand hygiene and PPE use were not followed during incontinent care for two residents with cognitive impairment and bowel/bladder incontinence. CNAs failed to sanitize hands before donning new gloves, changed gloves inconsistently after contact with soiled areas, placed wipes on an unsanitized overbed table, and one CNA walked in the hallway wearing a gown and gloves after leaving a resident room. Interviews confirmed the expected practice was hand hygiene during glove changes and disposal of gown and gloves inside the room.
Unsafe Room Conditions and Maintenance Deficiencies: A room on hall 600 had an uncovered electrical outlet and two holes in the walls, and a room on hall 100 had a broken window with glass on the windowsill. The Maintenance Director said he was responsible for room repairs but was not aware of the outlet cover issue or the wall holes, and the Administrator stated maintenance staff were responsible for ensuring rooms function properly.
Improper Wound Care Technique for Resident with Diabetic Heel Ulcer: An LVN provided wound care to a resident with a diabetic ulcer on the right heel but used gauze in a way that moved from the wound bed to the surrounding skin and back into the wound, and then reused the same gauze to pat dry both areas. The resident had a care plan and MD order for wound treatment, and the ADON and DON stated the proper method was to clean from the cleanest to the dirtiest area and discard gauze after use.
A resident with asthma and intact cognition had a bottle of nasal spray sitting on his side table in plain view, despite no physician order for the spray and no documented assessment showing he could self-administer medications. Staff stated the spray should not have been in the room and should have been stored in the med cart, and facility leadership confirmed that medications are not to be kept in residents’ rooms and that staff should scan rooms for medications.
Four dietary staff members, including cooks and aides, were found to be working without valid Texas Food Handler's Licenses despite being employed for over 30 days. Interviews revealed staff were unaware of the certification requirement, and the dietary manager and administrator could not provide documentation of completed training as required by state regulations.
Surveyors found that the facility failed to maintain proper kitchen sanitation and maintenance, including non-functioning handwashing sinks, poor drainage in the dishwashing area, and evidence of pest activity. Staff confirmed that these issues had persisted for over a month, and observations showed that food storage and preparation areas were not kept clean as required by facility policy.
The facility did not maintain the kitchen range hood in working order for an extended period, resulting in a nonfunctional hood and smoky conditions during meal preparation. Staff interviews confirmed the hood had been out of service for at least one to four months, affecting all residents who received food from the kitchen.
The facility did not maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen. Staff reported repeated sightings of rats and mice, evidence of rodents eating food, and ongoing issues with gnats. Pest control services were provided twice monthly, but pest activity and droppings persisted, and cleaning responsibilities were unclear among staff.
A resident with severe cognitive impairment and multiple diagnoses was not included, nor was their representative invited, in care plan meetings. Facility staff confirmed that the responsible party was not contacted for participation, and documentation of their involvement was lacking, despite facility policy requiring such inclusion.
A resident with multiple chronic conditions fell while attempting an unassisted transfer, resulting in injury. Although nursing staff documented that the physician, hospice, and family were notified, the resident's family reported not being informed of the incident until the resident was sent to the hospital. Documentation did not confirm timely or successful family notification, contrary to facility policy.
A resident with multiple medical and cognitive conditions made an allegation of rough care and inappropriate conduct by a hospice aide. The facility's investigation was incomplete, lacking identification of the alleged perpetrator, notification to hospice, and required documentation, with the DON not informed until much later. Facility policy for incident investigation and reporting was not followed.
A resident with severe cognitive impairment and multiple comorbidities was not promptly referred for dental services after losing dentures. Facility staff failed to communicate and document the issue, resulting in the resident not being included on the dental provider's appointment list until the deficiency was identified. The resident continued on a regular diet without assessment for chewing or swallowing difficulties, contrary to facility policy.
Three residents with cognitive impairment and orders for wander guards did not have these interventions documented in their care plans. Despite physician orders and progress notes indicating the use of wander guards for exit-seeking or wandering behaviors, the care plans failed to reflect this service. Facility staff confirmed that care plans were not updated to include the required interventions.
Two residents with severe cognitive impairment and a history of exit-seeking were not provided with functioning wander guard devices as required by their care plans and physician orders. Despite staff documentation indicating regular checks, direct observation showed that the devices were not active and did not trigger the alarm system when tested. This failure to ensure proper operation of safety devices resulted in inadequate supervision and increased risk of incidents.
A resident with hemiplegia and cognitive impairment experienced a slip during a transfer from a shower chair, which staff failed to report as a fall or document. No pain or skin assessments were performed, resulting in an undiagnosed fracture for 11 days. After hospitalization, the facility did not arrange the required orthopedic follow-up, and there was no documentation of communication with hospice regarding the appointment, leading to a prolonged delay in specialist care.
A resident with left-sided paralysis and cognitive impairment was transferred from a shower chair to a wheelchair by a CNA and an LVN without the use of a gait belt and while still wet, contrary to facility protocol. The resident slipped during the transfer and later was found to have sustained a comminuted fracture to the left shoulder. The incident was not immediately reported or documented, and staff interviews confirmed that required safety measures were not followed.
A resident receiving hospice care, who had significant physical and cognitive impairments, did not have a designated staff member responsible for coordinating care and communication with the hospice agency. Instead, multiple staff members were involved inconsistently, and the hospice social worker was not notified of important care events. Facility policy required a specific team member to be assigned for this role, but this was not done, resulting in lapses in communication and care planning.
Multiple residents reported and were observed to have issues with roaches and mice in their rooms and hallways, with evidence of pest activity such as droppings and food damage. Staff interviews confirmed ongoing pest problems, and record review showed lapses in pest control service and documentation, despite facility policy requiring regular treatment and monitoring.
A resident with hemiplegia and dementia experienced a slip in the shower chair during transfer, resulting in a shoulder fracture. The incident was not documented or reported by staff at the time, and there was no evidence of timely pain or skin assessment. Hospice staff later identified the injury and notified facility staff, but the required report to the State Agency was not made within the mandated 2-hour window, in violation of facility policy and regulatory requirements.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies in medication administration and documentation for two residents. One resident did not receive pain medications as ordered upon admission, while another did not receive intravenous antibiotics timely. The facility's policies on medication administration and documentation were not followed, leading to incomplete MARs and missing pharmacy delivery receipts.
A resident's request to receive medications at a later time was not honored, despite his care plan allowing for decision-making in his treatment regime. The resident, with multiple health conditions, refused medications offered earlier than his preferred time, and staff did not return to administer them later. The LVN cited no risk for missing one dose, while the DON emphasized medication administration without addressing self-determination.
A resident with moderate cognitive impairment was found using a portable heater in their room due to a malfunctioning in-wall unit. The heater, provided by the facility, was used for two days without direct supervision, posing a fire risk. Staff were unaware of the heater's presence, and no fire watches were conducted. The facility failed to provide a policy on portable heaters, highlighting inadequate supervision and potential hazards.
A resident with diabetes did not receive daily fasting blood sugar checks as ordered by the physician on multiple occasions. The resident was aware of the missed checks but did not report them, assuming facility management was aware. Interviews with staff indicated the checks were the responsibility of the overnight nurse, but there was no documentation of refusal by the resident. The DON and Administrator were unaware of the issue until it was reported.
A facility failed to provide a safe and homelike environment, as seen in a resident's bathroom and a communal shower room. The resident's bathroom had visible plumbing and smeared tiles, while the shower room was unsanitary with foul odors, missing tiles, and a black substance around the shower. Despite complaints, the Maintenance Supervisor was unaware of these issues, and no maintenance requests were logged. The shower room, the only functional one, was used for storing dirty linen and trash, worsening the conditions.
The facility failed to ensure a sharps container in the Hall 300 shower room was monitored and emptied before becoming overfilled, leaving used razors unsecured. The shower room door was found open and unattended, posing a risk to residents. Staff interviews confirmed the door should have been locked and the container emptied when full, as per facility policy. The DON and ADM acknowledged the potential hazard, emphasizing the responsibility of nursing staff to manage sharps disposal.
The facility failed to provide adequate pharmaceutical services, as expired medications and supplies were found in the medication room. This included IV administration sets, IV insertion cannulas, and acetaminophen suppositories. The deficiency potentially affected a resident receiving IV medications and another prescribed the expired suppositories. Interviews revealed a lack of awareness and accountability regarding the expired supplies, and the facility's policy on medication storage was not followed.
The facility failed to maintain essential kitchen equipment, resulting in a non-functional handwashing sink and drainage issues with the dishwashing sink and dishwasher. These problems persisted for over a year, posing risks of unsanitary conditions and staff injury. Despite efforts by the new Administrator and Dietary Manager to address the issues, they remained unresolved due to delays in receiving necessary invoices for funding.
The facility's pest control program was ineffective, as evidenced by live flies and roaches in the only active shower room. Observations and interviews with residents and staff confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' rooms. The pest control log showed sporadic entries, and staff acknowledged the issue but lacked consistent documentation and response.
Two residents in the facility were observed without privacy covers on their catheter bags, compromising their dignity and privacy. Despite care plans and facility policies emphasizing the importance of maintaining resident dignity, staff interviews revealed a lack of awareness and communication regarding the absence of these covers. The residents, one with severe cognitive impairment and the other with chronic health conditions, were left exposed, with their catheter bags visible from doorways.
A resident with a seizure disorder had an abnormal Keppra level that was not promptly reported to the physician, as required by facility policy. The lab results were not flagged in the electronic medical record system, leading to the oversight. The DON and ADON acknowledged the lapse, and the physician expected all lab results to be reported, despite routine monitoring not being deemed necessary unless symptoms were present.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and access to door codes. One resident was arrested after leaving the facility, while the other suffered a stroke and was hospitalized. The facility's failure to monitor and restrict access contributed to these incidents.
Two residents with dementia eloped from a facility due to inadequate supervision and failure to follow protocols. One resident, with moderate cognitive impairment, left unnoticed and was arrested for obstructing a train. The second resident, wearing a wander guard, eloped and suffered a stroke. Staff failed to perform required checks and ensure wander guard functionality, leading to these incidents.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and assistance devices. One resident, with dementia, left the facility after obtaining a door code from another resident and was later arrested for impeding a train. Another resident, at high risk for wandering, left the facility multiple times despite wearing a wander guard, and was found at a transfer station after suffering a stroke. The facility failed to effectively monitor and manage these residents' exit-seeking behaviors.
Two residents in an LTC facility did not receive scheduled showers or bed baths, as required for their ADL care. One resident, cognitively intact, reported not receiving bed baths due to staff shortages, while another with moderate cognitive impairment had inadequate documentation of care. Staff interviews revealed a lack of awareness and scheduling issues in the electronic care system, leading to the deficiency.
A facility failed to protect a resident's medical information when an LVN left a computer displaying wound care details unlocked and unattended. The resident, who was cognitively intact and had multiple medical conditions, had their privacy compromised as two residents and a visitor passed by the nurse's station during this time. The LVN admitted to the oversight, which violated the facility's policy on resident privacy.
A resident in an LTC facility was found with a 0.9% sodium chloride syringe left on his bedside table, contrary to State and Federal laws requiring drugs and biologicals to be stored in locked compartments. The resident, who was cognitively intact, reported that nurses often left items in his room. LVN D, the assigned nurse, acknowledged it was her responsibility to remove such items but did not recall leaving the syringe. The facility's policy mandates secure storage of medications, highlighting a lapse in adherence to these guidelines.
A facility failed to maintain an effective pest control program, leading to a gnat infestation in a resident's room. The resident, who was nonverbal, confirmed the issue but could not specify to whom it was reported. The LVN and DOM were unaware of the problem, despite the facility's pest control company visiting monthly and no pest reports documented in the maintenance logs.
The facility failed to update the daily nurse staffing information on one of the reviewed days. Observations showed that the posting near the dining room was outdated, displaying the previous day's date. The DON was unaware of the lapse, attributing it to the ADON not providing the necessary staffing sheets for the current pay period. The ADMIN confirmed the oversight and noted that the ADON and receptionist were responsible for the updates.
Failure to Supervise Resident Who Left Unattended
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with dementia and a history of cerebrovascular disease, hemiplegia/hemiparesis, hyperlipidemia, and hypertension. The resident’s records reflected varying cognitive scores over time, including a BIMS score of 8 on an annual assessment and an elopement risk rating that was documented as low on earlier assessments. Her care plan did not indicate that she could go out on pass without supervision or that she required special supervision, and the quarterly MDS was still in progress when the incident occurred. On the evening of the incident, the resident left the building without staff knowledge and was not located for approximately 24 hours. Staff documentation showed that she was first noted missing during rounds, with staff searching her room, the smoking area, the building, and the surrounding area. The resident did not sign out, and the facility’s sign-out list stated that only residents on the list were allowed to leave the building on their own; the resident’s name was not on the list at the time of review. A police report documented that officers responded to a missing person call and were told the resident had been missing since approximately 7:00 PM the prior evening. Interviews showed conflicting information among staff about the resident’s ability to sign out and her cognitive status. Some staff stated she should not have been allowed to leave unsupervised because of her dementia and fluctuating cognition, while others stated she could sign herself out based on a more recent BIMS score of 13. The resident later stated she did not remember the day she left, did not sign out, and did not tell anyone because she did not want staff to know she had left. The facility’s elopement policy required staff to determine whether a resident was authorized to leave, initiate a search if not authorized, and notify the administrator, DON, legal representative, attending physician, law enforcement, and volunteer agencies when a resident could not be located.
Failure to Maintain Clean, Safe, and Well-Maintained Environment in Resident Areas and Common Spaces
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, sanitary, and well-kept environment in multiple areas, including resident rooms, exit doors, and common areas. Observations on the 100, 200, and 300 halls showed exit glass doors with an accumulation of dark black dirt and leaves. The flooring in the dining room next to the kitchen entrance and ice machine was damaged, with torn vinyl exposing underlying material. Staff interviews revealed that housekeeping was responsible for cleaning resident rooms, but a CNA reported not observing housekeepers cleaning the doors and floors at the end of every hall. The Maintenance/Housekeeping Supervisor (MHS) stated he had not observed the soiled condition of the doors and acknowledged ongoing problems maintaining housekeeping staff. In one resident room, surveyors observed an air conditioning unit that was loose and separated from the wall, creating gaps, with gunk and matted black, sticky, greasy dirt around the unit and a hole in the wall structure to the right of the unit near the closet. The same room’s toilet was missing its tank cover. The MHS stated that bathroom repairs were his responsibility and that structural issues such as gaps and holes in walls were contracted out when he was notified. He also initially suggested that residents sometimes removed toilet tank covers, but after being given the specific room number, he acknowledged that this particular resident was unable to remove the tank cover. The ADON and CNA confirmed that all staff were responsible for reporting environmental and maintenance needs and that failure to report could result in residents living in unsanitary conditions.
Unsanitary Kitchen Conditions with Rodent and Gnat Activity
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an observation, surveyors noted an uncovered floor drain near the dishwashing area, which was left open after the Dietary Manager removed the cover while vacuuming standing water. In the dishwashing room, approximately 30 gnats were observed swarming over plates and old food on the tray rack. A large rat trap with a small food scooper was also observed stored on the bottom rack of a food preparation table in the kitchen, even though dining room staff were not actively preparing food at that time. Surveyors further observed a rodent exiting a plastic bag that had been placed over a non-operational kitchen sink near the prep area. The Dietary Manager later explained that the sink frequently stopped up, causing standing water, and that a plastic trash bag was used to cover the sink to prevent bugs, insects, and rodents from entering the kitchen. He acknowledged that the facility had a history of pest and rodent observations and that when the sink overflowed, gnats tended to multiply. Dietary staff present during the rodent observation declined to be interviewed about insect and rodent concerns in the kitchen. Interviews with the ADON, DON, Maintenance/Housekeeping Supervisor, and Administrator revealed that they were not aware of resident complaints or illnesses related to food, insects, or rodents, although they recognized that rodents, insects, and unsanitary conditions could make residents sick. Record review of a recent pest control visit documented the capture of multiple rats and mice in the kitchen and treatment for fruit flies and various crawling insects. The facility’s own sanitation policy required that kitchens and dining areas be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects, and that equipment and food-contact surfaces be maintained in good repair and cleanliness, which was not met under the observed conditions.
Failure to Maintain Effective Pest Control in Resident and Kitchen Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to prevent and address rodents and insects throughout the building, including resident rooms and the kitchen. An anonymous resident had a video dated 02/11/2026 showing a rodent on the floor near his bed on his side of the room; he reported that he did not notify staff at the time and had seen rodents in his area on two other occasions. Another resident reported seeing a rodent coming out of his closet at night on 04/07/2026. A CNA reported observing a rodent in a hallway on 04/07/2026 and stated that glue traps were placed in areas where rodents were observed and that a rodent had been removed from a glue trap that morning. Despite these resident and staff observations, the grievance log from 02/01/2026 to 04/07/2026 contained no entries related to rodents, pests, or insects. Surveyors observed gnats and a rodent in the kitchen during inspection on 04/08/2026, including a small rodent exiting a kitchen sink that had been covered with a clear plastic trash bag. The Dietary Manager acknowledged that the plastic trash bag was being used to cover a non-working sink in an attempt to prevent bugs, insects, and rodents from entering the kitchen and stated he did not have an answer for treatment of the gnats. The Business Office Manager reported personally seeing a rodent enter the front reception office and move down the hallway and described the issue as occurring on and off. The facility’s pest sighting log documented a rat observed in the front office on 04/06/2026, and the maintenance log also reflected a rodent observation in the front office on that date. Multiple staff members, including the ADON, SW, and DON, stated they had not personally observed rodents or insects and had not received resident reports of such issues, while also acknowledging that rodents and infestations could lead to resident illnesses due to unsanitary conditions and that all staff were responsible for reporting environmental concerns. The Administrator stated that the Maintenance/Housekeeping Supervisor was responsible for pest control and that pest control technicians were visiting daily, with glue traps checked and rodents removed. Pest control contractor records from February and March 2026 documented repeated captures of mice and rats in the kitchen and treatment for fruit flies and other insects, as well as observations of exterior structural issues such as moisture damage, holes in exterior walls, cracks in mortar and bricks, and gaps and rotten structures. The facility’s pest control policy, dated May 2008, stated that the building was to be kept free of insects and rodents through an ongoing pest control program, with proper materials and procedures, daily removal of garbage and trash, and maintenance assistance as needed, but the documented observations and contractor reports showed ongoing rodent and insect activity in resident and food service areas during the review period. Pest control service documentation further showed that during multiple visits, the pest control contractor captured numerous rodents and treated for fruit flies and other crawling insects in the kitchen, common areas, and resident rooms. One service description for commercial rodent premium coverage outlined sealing potential rodent entry points, mass trapping, additional exterior bait stations, and ongoing inspections to identify and repair new entry points, indicating that significant rodent activity had been identified and required extensive intervention. Despite these findings and the facility’s written policy requiring an effective pest control program, the presence of rodents and gnats in resident care and food preparation areas, combined with the lack of corresponding grievances and inconsistent staff awareness of resident reports, demonstrated that the facility did not effectively implement or maintain its pest control program during the period reviewed.
Unsecured Oxygen Cylinder at Nurse’s Station
Penalty
Summary
The facility failed to provide a safe environment by not securely storing one of two oxygen cylinders observed at a nurse’s station. During observation, two oxygen cylinders were seen next to the crash cart behind the nurse’s station, with one cylinder properly secured in a rack and the other left unsecured. Later observation and interview with an LVN confirmed the oxygen tank was not secured; the LVN stated she had just started her shift, had not noticed the unsecured tank, and acknowledged it should always be secured in a rack because it was a hazard and could cause a fire. In a subsequent interview, the DON stated she was not aware the tank was unsecured, explained that night shift staff had been tasked with checking crash carts and had probably changed out the tank and forgotten to return it to the storage room, and stated her expectation that tanks be secured at all times because they could be knocked over. The DON also reported that the facility did not have a policy on oxygen storage, despite NFPA 99, 2012 Edition, Section 11.6.2.3 requiring freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart. No specific residents were identified as directly involved at the time of the observation, and no resident medical histories or conditions were described in relation to this deficiency.
Delayed Weekend Mail Distribution
Penalty
Summary
The facility failed to ensure residents had the right to send and receive mail and to receive letters, packages, and other materials delivered to the facility or resident through a means other than a postal service, including privacy of such communications, for 6 of 6 confidential residents reviewed for resident rights. During a confidential resident group meeting, all 6 members stated they never received mail on Saturdays because the Business Office did not work on Saturdays, although a receptionist was present. Interviews with the Administrator and Receptionist showed that mail was dropped off at the front desk and that both the Administrator and receptionist passed out mail, but the receptionist stated that when she returned on Monday, the mail had not been passed out. The Administrator later stated that mail should be passed out on the weekends by the weekend receptionist on Saturday.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for multiple dates reviewed across several months. The report states the facility did not provide RN coverage for 8 consecutive hours daily on numerous listed dates from 10/19/24 through 09/28/25, and that the facility triggered for no RN hours on the PBJ Staffing Data Report for Quarter 2, Quarter 3, and Quarter 4 of 2024. Review of the employee list showed there were no other RN nurses on the facility’s employee list. During interviews on 12/16/25, the DON stated she was hired on 08/11/2025 and was the only RN providing RN coverage. She stated the facility had no RN weekend coverage, could not provide 8-hour daily RN coverage, and did not use agency staffing for RN coverage. The Administrator confirmed the PBJ hours were correct, stated the DON was the only RN, and said the DON worked four hours on Saturdays and Sundays but could not provide 8-hour daily coverage. He also stated the facility did not use agency staff for RN coverage and that weekend nurses were LVNs, not RNs. The facility’s staffing policy stated it provides sufficient nursing staff with the skills and competencies necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.
Improper Food Labeling and Dating in Kitchen Storage
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety in the facility’s only kitchen. During observation, surveyors found 5 bins of dry goods in the kitchen storage area, including rice, flour, breadcrumbs, potatoes, and beans, with only one date marked on a label. The labels on these bins did not identify the exact item inside, when it was placed there, or when it should be discarded. In the dry storage area outside the kitchen, surveyors observed previously opened packages with no dates on them. There was a package of tortillas with no label to indicate what it was, when it was opened, or when it should be discarded, and a package of puree rice with a date of 09/18 and nothing else on the label. The weekend cook stated she had only worked at the facility a few weeks and that the food had already been put up when she arrived to work. The Dietary Manager stated the packages are supposed to be labeled after they are taken from the box and opened, and believed weekend staff may not be labeling the packages after opening them. The Administrator stated he did not know the packages were not meeting the labeling requirement for dates and identification.
PASRR Screening and Assessment Submission Failures
Penalty
Summary
PASRR Level I screening was not kept accurate for Resident #5 after the resident later developed additional psychiatric diagnoses. The resident’s face sheet listed diagnoses including unspecified dementia without behavioral disturbance, psychotic disorder with delusions, post-traumatic stress disorder, and bipolar disorder, and the MDS assessment also reflected bipolar disorder, psychotic disorder, and post-traumatic stress disorder. The resident’s PASRR Level I screening dated 10/31/23 showed he did not qualify for a PASRR Level II evaluation at that time, and the record review found no evidence that any additional PASRR screenings or evaluations had been completed after the initial screening, despite the later bipolar diagnosis. Resident #10’s PASRR process was also not completed within the required timeframe for specialized services. The resident’s face sheet listed diagnoses including Duchenne or [NAME] muscular dystrophy, chronic pain syndrome, unspecified dementia without behavioral disturbance, and major depressive disorder, and the MDS assessment reflected Duchenne or [NAME] muscular dystrophy. The PASRR report showed the facility failed to submit assessments for all three therapy disciplines within the 20-day deadline to PASRR staff. During interview, the PASRR habilitation coordinator stated the facility had 20 days to send the physical, occupational, and speech assessments after the resident selected services, but the deadline was missed and the resident would have to wait for another quarterly meeting to restart the process.
Expired Insulin and Personal Beverages on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident reviewed for pharmaceutical services. Resident #58 was a male resident with diabetes mellitus, moderate cognitive impairment with a BIMS score of 10, and a care plan intervention to administer diabetes medications as ordered. A physician order dated 10/26/2025 directed Humalog insulin injections before meals and at bedtime for type 2 diabetes mellitus with hyperglycemia. During an observation of the medication room on 12/15/2025 at 10:09 AM, a vial of Humalog with an opening date of 09/24/2025 was found inside the medication room refrigerator. LVN A stated she was not sure of the expiration date and took the insulin out of the medication room. The ADON later stated the Humalog had already been disposed of because it was expired and explained that Humalog has a 28-day shelf life after opening. LVN B, who was administering Resident #58's insulin, stated the vial was from the resident's former facility and was not being used, but should not have been in the refrigerator because it could be accidentally used. The facility also failed to keep personal beverages off medication carts during medication pass. Observation showed LVN B's personal tumbler on top of the medication cart while passing medications, and later MA G's water bottle was also on top of a medication cart during medication pass. Both staff members stated the beverages should not have been on the carts because of cross contamination and possible medication mix-up. The ADON and DON stated personal beverages should not be on medication carts, and the DON stated nurses were responsible for checking medication expiration dates each time medications were administered. The facility policy stated that the expiration or beyond-use date must be checked prior to administering and that the date opened must be recorded on multi-dose containers.
Hand Hygiene and PPE Use During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents who were incontinent of bladder and bowel and required assistance with toileting and incontinent care. Resident #34 was a female with muscle weakness and moderate cognitive impairment with a BIMS score of 09. Resident #42 was a male with benign prostatic hyperplasia and severe cognitive impairment with a BIMS score of 07. Both residents had care plans reflecting the need for assistance with toileting or incontinent care. During observation of Resident #34's incontinent care, CNA E washed her hands and put on gloves, then cleaned the resident's perineal area and bottom. After removing her gloves, she did not sanitize her hands before putting on a new pair of gloves. She also did not sanitize her hands before putting on another pair of gloves after cleaning the resident's bottom and before handling the new brief. In interview, CNA E stated hands should be sanitized before putting on new gloves because her hands might be dirty from cleaning the resident's bottom and touching the new gloves with dirty hands rendered the new gloves dirty. During observation of Resident #42's incontinent care, CNA D washed her hands and put on gloves, placed wipes on the resident's overbed table without sanitizing the table, cleaned the resident's perineal area, changed her gloves without sanitizing her hands first, and later cleaned the resident's bottom. After that, she did not change her gloves before touching the new brief and placing it under the resident. In a separate observation, CNA F was seen walking in the hallway wearing a gown and gloves after leaving the room of a resident with a catheter. Interviews with CNA D, CNA F, the ADON, the DON, and the Administrator confirmed that hand hygiene should occur during glove changes and that gowns and gloves should be discarded before leaving the room to prevent spread of infection.
Unsafe Room Conditions and Maintenance Deficiencies
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 4 halls reviewed for environmental concerns, specifically halls 100 and 600. On hall 600, a room had an electrical outlet without a cover, with no wires exposed, and the same room had two holes in the walls, one at the bottom right of the clothes storage area and another in the corner near the window. On hall 100, a room had a broken window with glass on the windowsill. During interview, the Maintenance Director stated he was responsible for room repairs, that clinical staff could notify him when something was broken, and that he also did rounds of the rooms. He stated he was not aware of the holes in the walls or the uncovered outlet in the hall 600 room, and he was only aware of the broken window in the hall 100 room. He stated he was notified that a resident threw a tray and broke the window, that the window was double-lined so only the inside panel broke, and that he tried but was unable to remove the broken glass. The Administrator stated maintenance staff were responsible for ensuring rooms function properly, was not aware of the holes in the walls or missing outlet covers, and was aware of the broken window and that the resident was moved to another room until the cosmetic damage was repaired.
Improper Wound Care Technique for Resident with Diabetic Heel Ulcer
Penalty
Summary
The facility failed to ensure that wound care was provided according to professional standards of practice for one resident with a diabetic ulcer on the right posterior heel. The resident was cognitively intact with a BIMS score of 14 and had a care plan directing treatment as ordered. The physician order required the wound to be cleaned with normal saline or wound cleanser, patted dry, and then treated with Anasept, collagen, and a dry dressing three times weekly. During observation, an LVN prepared wound care supplies and cleaned the resident’s right heel wound, but used gauze in a way that crossed from the wound bed to the surrounding skin and then back into the wound. She also used the same gauze to pat dry the wound, the surrounding skin, and then the wound again. In interviews, the LVN, ADON, and DON stated that the wound should be cleaned from the cleanest to the dirtiest area, gauze should be discarded after use, and the same gauze used on the surrounding skin should not be used again inside the wound. The facility policy stated that wound care is intended to promote healing.
Unsecured Nasal Spray Found in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and to limit access to authorized personnel when a bottle of nasal spray was found on Resident #43’s side table in plain view. Resident #43 was a cognitively intact male with asthma, admitted to the facility and documented on the MDS as having a BIMS score of 15. His care plan included giving medications as ordered, but the physician orders reviewed on 12/14/2025 did not include an order for nasal spray, and the assessment notes showed no assessment for self-administration of medications, no clear instructions for self-administration, and no determination that he was competent to manage his own medications. During observation, the resident was awake in bed and stated the nasal spray was his and had always been on his side table; he was not sure whether staff knew it was in the room. An LVN stated the nasal spray should not be in the room unless the resident had been assessed as able to administer it himself, and that if needed it should be stored in the cart and administered by staff. The ADON, DON, and Administrator each stated that medications should not be stored in residents’ rooms and that staff should scan rooms for medications; the DON also stated the nasal spray should be stored in the cart. The facility policy reviewed stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner and that only authorized persons may prepare and administer medications.
Failure to Ensure Dietary Staff Hold Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets, as evidenced by four out of five reviewed dietary staff members lacking a valid Texas Food Handler's License. Record reviews confirmed that Cook A, three other dietary staff, and a dietary aide had all been employed for more than 30 days without obtaining the required certification. Multiple interviews with these staff members revealed they were unaware of the requirement or the timeframe for obtaining the food handler's license. The new dietary manager, hired nine days prior to the survey, also confirmed she could not locate any current food handler certificates for these staff members and acknowledged her responsibility for ensuring staff training and certification. Further interviews with the Administrator and dietary manager indicated a lack of oversight and understanding regarding the process and timeline for obtaining food handler certification. Despite requests, the facility was unable to provide documentation of food handler licenses for the kitchen staff prior to the survey exit. Review of Texas Department of State Health Services regulations confirmed that all food employees, except for the certified food protection manager, must complete accredited food handler training within 30 days of employment, and the facility must maintain certificates on the premises.
Deficient Kitchen Sanitation and Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food service safety and sanitation. Both handwashing sinks were not in proper working order: one leaked from a pipe beneath the sink, requiring a basin to catch water, while the other was non-functioning with no running water from the faucet. The dishwashing room also had drainage issues, with water not draining properly and staff using a wet vacuum to remove water from the floor. Pest droppings were found in all three sections of a nonfunctioning dishwashing sink and on the floor beneath another nonfunctioning sink, and several gnats were observed in the nonfunctioning handwashing sink. Interviews with staff confirmed that the plumbing and drainage issues had persisted for at least a month and a half. Staff described using a wet vacuum to manage water overflow due to the drainage problem. The dietary manager and administrator were aware of the plumbing and pest issues, with the dietary manager stating that plumbing was a top priority and the administrator confirming knowledge of the problems prior to the survey. The facility's Nutrition Services Policy & Procedures required food storage areas to be kept clean at all times, but observations indicated this standard was not met.
Failure to Maintain Kitchen Range Hood in Safe Working Order
Penalty
Summary
The facility failed to maintain the kitchen range hood in good repair, resulting in the equipment being nonfunctional for an extended period. Multiple staff interviews confirmed that the range hood had not worked for at least one to four months, during which time the kitchen would become smoky when cooking on high. Staff reported that all residents received food prepared in this kitchen. The Dietary Manager (DM) and other staff were aware of the issue, and there were occasions when the kitchen was full of smoke due to the inability to use the range hood. The Administrator acknowledged awareness of the nonfunctional range hood prior to the survey and stated that a work order and quotes for repair had been obtained. The maintenance service policy required that equipment be maintained in a safe and operable manner at all times, but the range hood remained out of service until after the deficiency was identified. The facility census at the time was 68 residents, all of whom relied on the kitchen for meals.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen over multiple days. Observations included pest droppings in all three sections of a nonfunctioning dishwashing sink, another nonfunctioning sink, and on the floor beneath that sink. Five gnats were observed in a nonfunctioning hand washing sink near the dishwasher. Multiple staff interviews confirmed repeated sightings of rats and mice in the kitchen and pantry, with one staff member reporting that bread had to be stored in the freezer due to rodents eating through packaging. Staff also reported that rodents had been caught in traps and that gnats were present throughout the kitchen. The Maintenance Director stated that the rodent issue began after concrete was broken up on the back patio and had been addressed with sticky bait, but he was unaware of ongoing sightings in the kitchen. Pest control services were documented as occurring twice per month, with logs indicating recent captures of mice and fruit flies. The Administrator acknowledged the presence of pest droppings and stated that kitchen cleaning was the responsibility of the dietary manager, but was unsure when the droppings were last cleaned. The facility's pest control policy emphasized frequent treatment and monitoring, but the observed conditions and staff reports indicated that the kitchen was not being maintained free of pests.
Failure to Include Resident Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was invited to participate in the development and implementation of the resident's person-centered care plan. Record reviews and interviews revealed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 3 and diagnoses including Alzheimer's disease, heart failure, hypertension, and a psychotic disorder, was not able to respond to questions and relied on a responsible party for decision-making. Despite this, there was no evidence that the responsible party was invited to or included in care plan meetings. Interviews with facility staff, including the social worker (SW), MDS coordinator, and administrator, confirmed that the SW was responsible for coordinating care plan meetings and inviting responsible parties or family members. However, the SW admitted to not having coordinated a care plan meeting for the resident in question during her tenure. The responsible party also reported never being invited to a care plan meeting, despite being contacted for medical consents and expressing a desire to be included. The MDS coordinator could not recall if the responsible party was invited to the most recent care plan meeting and was unable to provide sign-in sheets or documentation showing their participation. Review of the resident's care conference assessments showed attendance by facility staff but no indication that the responsible party or family attended. Additionally, the facility's policies required resident and/or representative participation in care planning and outlined procedures for notifying them in advance, but these were not followed in this case. Documentation for some care plan meetings was missing, further indicating a lack of compliance with established procedures.
Failure to Notify Family of Resident Injury After Fall
Penalty
Summary
The facility failed to notify a resident's representative following an incident that resulted in injury. A male resident with multiple diagnoses, including type 2 diabetes with foot ulcer, atherosclerotic heart disease, congestive heart failure, and stage 3 chronic kidney disease, experienced a fall while attempting to transfer from his bed to a wheelchair without assistance, despite requiring a two-person assist and a Hoyer lift for transfers. The resident was later observed with swelling to his face and right arm, and was subsequently sent to the hospital after physician notification. Interviews with nursing staff revealed inconsistencies in the notification process. One nurse stated she notified the physician, hospice, and family members after the fall, while another nurse relied on previous charting that indicated family notification had occurred. However, the resident's family member reported not being informed of the fall until the resident was being sent to the hospital, and documentation did not clearly indicate whether a message was left or if follow-up attempts were made after an initial unsuccessful call. Record reviews showed that progress notes and incident reports documented that the physician, hospice, and family were notified, but there was no conclusive evidence that the family was actually reached or informed in a timely manner. The facility's policies required immediate notification of family and documentation of such notifications following incidents or changes in condition, but these procedures were not consistently followed in this case.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a resident with multiple diagnoses, including dementia, schizoaffective disorder, and cognitive communication deficit, made an allegation that a hospice aide was rough during perineal care and did not stop when requested. Additionally, the resident alleged inappropriate sexual contact and racial slurs by a hospice aide. The investigation report completed by the previous administrator did not identify the alleged perpetrator, lacked documentation that hospice was notified, did not include safe surveys, and failed to provide evidence of abuse and neglect in-services being conducted. Interviews revealed that the hospice Director of Nursing was not notified of the allegation until months later, and the current administrator, who was not involved in the original investigation, could not locate further information or documentation regarding the incident. Facility policy required thorough documentation of incidents, including witness accounts, physician notification, and corrective actions, but these elements were missing from the investigation. The resident later stated they did not recall the alleged abuse, but the lack of a comprehensive investigation and documentation was evident.
Failure to Timely Refer Resident for Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining routine and emergency dental care in a timely manner. The resident, an elderly male with Alzheimer's disease, chronic obstructive pulmonary disease, and a history of subdural hemorrhage, was admitted to the facility with his own teeth intact according to initial assessments and care plans. However, subsequent observations and interviews revealed that the resident had no upper or lower teeth and could not recall what happened to his dentures or missing teeth. Despite this, there was no documentation or prompt referral for dental services when the dentures were reported missing. Interviews with facility staff indicated a lack of communication and unclear responsibility regarding the referral process for dental care. The Assistant Director of Nursing (ADON) stated she was not informed about the missing dentures and believed it was the responsibility of the Social Worker (SW) to submit referrals. The SW reported receiving a verbal complaint from the resident's family about the missing dentures but could not provide documentation or a specific date for when a referral was made. The resident was not initially included on the list for upcoming dental appointments, and only after further inquiry was a referral form completed and the resident added to the list. Further interviews with the Director of Rehabilitation, Dietitian, and Administrator confirmed that there was no prior notification or assessment regarding the resident's missing dentures or need for a diet change. The resident continued on a regular diet without documented chewing or swallowing difficulties, and staff were unaware of the dental issue until it was brought to their attention during the survey. Facility policy required prompt referral and documentation for such issues, which was not followed in this case.
Care Plans Lacked Documentation of Wander Guard Interventions
Penalty
Summary
The facility failed to ensure that the care plans for three out of four residents included documentation of services provided, specifically the use of wander guards. For one resident with severe cognitive impairment and a history of exit-seeking behavior, the care plan did not document the presence of a wander guard, despite physician orders and progress notes indicating its use. This resident had diagnoses including unspecified dementia, psychotic and mood disturbances, anxiety, hypertension, hypothyroidism, edema, and psychotic disorders with hallucinations and delusions due to physiological conditions. The resident's progress notes reflected active exit-seeking behavior, and orders were in place for a wander guard to be checked every 10 hours, but this intervention was not reflected in the care plan. Another resident, also with severe cognitive impairment and daily wandering behavior, had similar omissions. This resident's diagnoses included unspecified dementia, psychotic and mood disturbances, anxiety, sequelae of cerebral infarction, neuroleptic-induced Parkinsonism, chronic kidney disease stage 4, hypertension, anemia, cognitive communication deficit, difficulty in walking, and schizoaffective disorder. Despite daily wandering and an order for a wander guard, the care plan did not document this intervention. Progress notes indicated active exit-seeking behavior, but the care plan failed to reflect the use of the wander guard as an intervention. A third resident, with moderate cognitive impairment and no documented wandering behavior, also had an order for a wander guard, but the care plan did not include this intervention. Diagnoses for this resident included unspecified dementia, psychotic and mood disturbances, anxiety, hypothyroidism, difficulty in walking, generalized muscle weakness, and unspecified pain. The care plan lacked documentation of the wander guard, even though orders were in place for its use. Interviews with facility staff confirmed that the care plans were not updated to reflect the use of wander guards for these residents.
Failure to Ensure Functioning Wander Guard Devices for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that two residents with severe cognitive impairment received adequate supervision and functioning assistance devices to prevent incidents related to wandering and potential elopement. Both residents had diagnoses including unspecified dementia, psychotic disturbances, mood disturbances, and anxiety, with one also experiencing neuroleptic-induced Parkinsonism and chronic kidney disease. Documentation showed that both residents had orders for wander guard devices to be present and functioning on their lower extremities, with checks required every shift and specific instructions to test the devices at the front door to ensure alarms would sound. Despite these orders, observations revealed that neither resident's wander guard device was functioning properly at the time of survey. When tested at the front door, the devices did not activate the alarm, although the door alarm itself was operational. Staff interviews confirmed that checks for placement and functioning of the wander guards were documented as completed every shift, but the devices were not active during the survey. The ADON and maintenance staff stated that the system was checked regularly, and maintenance logs indicated that the system had passed recent checks. However, the handheld device used to activate or deactivate the wander guards was found to be inactive during the survey. Further review of records and interviews indicated that the facility had experienced previous issues with the wander guard system, including a recent repair to the front door alarm system. Despite staff and administrative claims that the system was functioning and that no residents had eloped, the direct observation of non-functioning wander guards for two residents with a history of exit-seeking behavior constituted a failure to provide adequate supervision and accident hazard prevention as required.
Failure to Report Fall, Assess Pain, and Arrange Follow-Up Care After Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely pain assessments and follow-up care for a resident with significant medical needs, including hemiplegia, vascular dementia, and aphasia. The resident experienced a slip during a transfer from a shower chair to a wheelchair, which was not reported as a fall by the staff involved. There was no documentation of the incident, pain, or skin assessments in the resident's records for the relevant period. The incident was only brought to the facility's attention after the resident and family reported ongoing pain, leading to a delayed diagnosis of a comminuted fracture in the left humeral bone, which went undetected for 11 days. The staff involved in the transfer did not use a gait belt and did not report the slip or any potential injury, as they believed the resident had not fallen and showed no immediate signs of pain or injury. The lack of reporting meant that the incident was not entered into the facility's accident log, and no immediate medical evaluation or x-ray was performed. The resident continued to experience pain, which was eventually communicated to hospice staff, who then notified the facility nurse and ordered pain medication. However, the underlying injury remained undiagnosed until the family intervened and requested further assessment. Additionally, after the resident was hospitalized and discharged with an order for an orthopedic follow-up, the facility failed to arrange the required appointment. There was no documentation that the hospice agency had been contacted regarding the follow-up, and the appointment was not made for several months. Interviews with facility staff revealed confusion over responsibilities for arranging such appointments, particularly in the absence of the social worker, resulting in a prolonged lack of necessary specialist care for the resident.
Failure to Use Gait Belt and Dry Resident During Transfer Results in Serious Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistive devices during a transfer. Specifically, a male resident with left-sided hemiplegia, vascular dementia, and aphasia required substantial assistance for transfers and was dependent on staff for mobility and toileting. During a transfer from a shower chair to a wheelchair, staff did not use a gait belt as required by facility protocol, and the resident was not dried off prior to the transfer, resulting in the resident slipping and sustaining a comminuted fracture to the left humeral neck and glenoid bone. The incident was not immediately reported or documented in the facility's records. The resident did not report the incident until several days later, and there was no evidence in the facility's incident log or electronic health record of a fall, near fall, or injury during the relevant period. Staff involved in the transfer stated that the resident began to slip but was caught before falling, and no pain or injury was reported at the time. However, subsequent medical evaluation revealed significant fractures, and the resident required additional pain management and orthopedic consultation. Interviews with staff and review of facility policy confirmed that the use of a gait belt and ensuring the resident was dry before transfer were required safety measures that were not followed. The facility's policy also required ongoing assessment of residents' transfer needs and proper documentation, which was not evident in this case. The failure to adhere to established protocols and to document and report the incident led to the identification of an Immediate Jeopardy situation.
Failure to Designate Staff for Hospice Communication and Coordination
Penalty
Summary
The facility failed to designate a specific interdisciplinary team member responsible for collaborating with hospice representatives and coordinating the participation of LTC facility staff in the hospice care planning process for residents receiving hospice services. Instead, communication with hospice agencies was handled inconsistently, with various staff members such as nurses, the DON, the Administrator, and the Social Worker all potentially communicating with hospice, but without a clear assignment of responsibility. This lack of a designated point of contact was confirmed in interviews with the Administrator and DON, who both stated that no single person was assigned to communicate with hospice agencies. A resident with a history of hemiplegia, vascular dementia, and aphasia was admitted to the facility and later placed on hospice care. The resident required significant assistance with activities of daily living and had moderate cognitive impairment. Record reviews showed that the resident was admitted to hospice services, but there was no evidence that a specific staff member was coordinating care or communication with the hospice agency as required by facility policy. Further, the hospice social worker reported not being notified by the facility about the resident's follow-up appointments or receiving discharge paperwork after a hospital visit. The facility's policy required a designated team member to coordinate care and communication with hospice, but the policy form was left blank regarding the responsible individual's name and title. This failure to assign and document a responsible staff member led to gaps in communication and coordination of care for the resident receiving hospice services.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and rodents in multiple resident rooms and a main hallway. Observations and interviews revealed that several residents saw roaches in their rooms and hallways, with some reporting the issue had been ongoing for months. One resident reported seeing mice in his room, with small black pellets observed under his air conditioning unit. Another resident reported mice chewing through his food, with similar pellets found behind his refrigerator and in his closet. Residents stated they had informed staff about these pest issues. The Maintenance Supervisor confirmed there had been a significant roach problem previously due to non-payment to the pest control company, resulting in missed treatments. He also acknowledged an ongoing mouse problem and recent placement of traps. Review of pest management records showed sporadic documentation of pest sightings and a lack of receipts or evidence of pest control service visits for several months. The facility's pest control policy required frequent and periodic treatments, monitoring, and prompt reporting, but these measures were not effectively implemented as evidenced by the continued presence of pests.
Failure to Timely Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident involving a resident with left-sided hemiplegia, vascular dementia, and aphasia was not reported to the State Agency within the mandated timeframe. The resident, who required substantial assistance for activities of daily living, experienced a slip in the shower chair while being transferred, which was not documented or reported at the time of occurrence. The incident was initially not recognized or documented by facility staff, and there was no evidence of a fall, skin, or pain assessment in the resident's records for the relevant dates. The resident later reported pain and a fall to hospice staff, who then notified the facility nurse and ordered pain medication. Despite this, the facility's incident and accident log did not reflect any record of the event, and the required reporting procedures were not followed. Interviews with staff revealed confusion and assumptions regarding who was responsible for reporting the incident, leading to a delay in notification to the Director of Nursing and the Administrator. The facility's policy required prompt investigation and reporting of all accidents or incidents, with documentation to be submitted to the Director of Nursing within 24 hours. However, in this case, the policy was not followed, and the incident was not reported to the appropriate authorities within the required 2-hour window. This lapse in procedure was confirmed through interviews and record reviews, which showed a lack of timely communication and documentation regarding the resident's fall and subsequent injury.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration and documentation. For one resident, the facility did not administer pain medications as ordered upon admission, despite the resident's request for pain relief. The resident, who had diagnoses including sepsis, polyneuropathy, and paraplegia, did not receive oxycodone until more than 24 hours after admission. The facility also failed to administer and document scheduled doses of gabapentin and trazodone for this resident, leading to a delay in pain management and insomnia treatment. Another resident, admitted with conditions such as a multidrug-resistant organism and septicemia, did not receive intravenous antibiotics as ordered. The facility failed to acquire and administer the antibiotics timely, and there were gaps in the medication administration record (MAR) for several medications. The resident's family reported that the facility did not provide medications for a day and a half after admission, and the resident eventually chose to go to the hospital to receive the necessary antibiotics. The facility's documentation and communication with the pharmacy were inadequate, contributing to the delay in medication delivery. The facility's policies on medication administration and documentation were not followed, resulting in incomplete MARs and missing pharmacy delivery receipts. The Director of Nursing (DON) acknowledged the delays in medication delivery and the lack of documentation for some medications. The facility's failure to ensure timely and accurate medication administration placed residents at risk of inadequate disease management and uncontrolled pain.
Failure to Honor Resident's Medication Timing Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his request to receive medications at a later time. The resident, who had diagnoses including sepsis, polyneuropathy, muscle spasm, and paraplegia, expressed his preference to receive his medications later in the evening, as he was accustomed to from his previous hospital stay. On the evening in question, the resident refused his medications when they were offered earlier than his preferred time, leading to a situation where his choice was not respected. The resident's care plan indicated that he was resistive to care and should be allowed to make decisions about his treatment regime. Despite this, the staff did not return to administer the medication at the time requested by the resident. The LVN involved acknowledged the resident's refusal and did not attempt to administer the medication later, citing no risk to the resident for missing one dose. The DON confirmed that medications should be administered as ordered but did not address the importance of respecting the resident's self-determination in care decisions.
Inadequate Supervision and Hazardous Equipment Use in Resident's Room
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accident hazards for a resident who was using a portable heater in their room. The resident, who had moderate cognitive impairment and required assistance for transfers and personal hygiene, was found with a portable heater operating within close proximity to their bed and privacy curtain. The heater was provided by the facility due to a malfunctioning in-wall heating unit, and the resident had been using it for two days without direct supervision. Interviews with staff revealed a lack of awareness and monitoring regarding the use of portable heaters in the facility. The Maintenance Supervisor acknowledged the potential fire risk posed by the heater and stated that it had been removed after replacing the in-wall unit. However, no fire watches were conducted during the heater's use, and the facility did not provide a policy on portable heaters when requested. This oversight placed residents at risk for accidents or injuries due to inadequate supervision and potential fire hazards.
Failure to Follow Physician Orders for Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow physician orders for daily fasting blood sugar checks for a resident on multiple occasions. The resident, who was cognitively intact and had a history of diabetes mellitus with neuropathy, was aware that his blood sugar should be checked every morning but reported that the facility nurses did not perform these checks consistently. The resident did not report the missed checks to facility management, assuming they were already aware of the issue. Interviews with facility staff revealed that the responsibility for the blood sugar checks was assigned to the overnight nurse, but there was no documentation indicating that the resident refused the checks. The Director of Nursing (DON) and the Administrator were not aware of the missed checks until the issue was brought to their attention. The facility's medication administration record confirmed the missed checks, and there was no related policy provided by the DON or Administrator before the exit.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions in Resident #8's bathroom and the shower room used by multiple residents. Resident #8, who has a history of major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and mild cognitive impairment, reported that her bathroom wall had been in disrepair since her admission, with visible plumbing and smeared tiles. Despite her complaint to the Maintenance Supervisor, no action was taken, and the issue was not logged in the maintenance records for several months. Additionally, the shower room on the 300 hall was found to be unsanitary and in poor condition, with a strong foul odor, missing tiles, and a black substance around the shower edges. Residents reported the room as "nasty" and infested with roaches, with dirty briefs and overflowing trash contributing to the unsanitary conditions. The Maintenance Supervisor was unaware of these issues, as no maintenance requests had been submitted, and the room's condition was not documented in the maintenance logs. Interviews with staff revealed that the shower room was the only functional one available, and it was used to store dirty linen and trash, exacerbating the odor and cleanliness issues. The Assistant Director of Nursing (ADON) acknowledged the problem but had not yet found an alternative storage solution. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the lack of cleanliness and order in the resident's bathroom and the communal shower room.
Failure to Secure Sharps Container and Shower Room
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that a sharps container in the shower room on Hall 300 was properly monitored and emptied before becoming overfilled. Observations revealed that the sharps container was overflowing past the fill line, with five used disposable razors left unsecured on top. The shower room door was found open and unattended, posing a risk of injury to residents who might access the room unsupervised. Interviews with staff, including a medication aide and a licensed vocational nurse, confirmed that the door should have been locked and the sharps container emptied when full. Both staff members acknowledged the potential hazard posed by the unsecured razors. The Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy required used razors to be disposed of in sharps containers and that these containers should be emptied when reaching the fill line. The DON stated that all nursing staff were responsible for ensuring the containers were emptied, and keys to the containers were accessible to staff. Despite these protocols, the failure to secure the shower room and properly manage the sharps container created a potential risk for residents, particularly those with dementia, who could have accessed the razors and harmed themselves.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the presence of expired medications and supplies in the medication room. During an observation, it was noted that the medication room contained an almost full box of IV administration sets with an expiration date of June 5, 2024, ten IV insertion cannulas with an expiration date of February 28, 2024, and six acetaminophen 650mg suppositories with a use-by date of December 11, 2023. These expired items were not removed or disposed of according to the facility's policy, which states that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. The deficiency potentially affected two residents: one receiving IV medications and another prescribed the expired acetaminophen suppositories. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed a lack of awareness and accountability regarding the expired supplies. The ADON mentioned that the medication room was checked monthly for expired items, but the expired supplies were still present. The DON acknowledged the risk posed by the expired IV supplies but did not specify who was responsible for monitoring expiration dates. The facility's policy on medication storage was not adhered to, leading to the presence of expired medications and supplies in the medication room.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, as evidenced by issues with essential kitchen equipment. Specifically, the handwashing sink in the kitchen was non-functional, with no running water available from the faucet. Additionally, the dishwashing sink and dishwasher were unable to drain properly, leading to water accumulation. These deficiencies were observed during a survey of the kitchen, where a wet vacuum was noted to be used to manage the water overflow, indicating a persistent drainage problem. Interviews with the Dietary Manager and the Administrator revealed that these issues had been ongoing for at least a year. The Dietary Manager acknowledged the risk of injury to staff and the potential for an unsanitary kitchen environment due to the drainage problems. The Administrator, who took over the facility in June 2024, confirmed that the issues were known during the turnover with the previous administrator. Despite attempts to resolve the problems, including hiring a new dietary manager and contacting plumbers, the issues remained unresolved due to delays in receiving necessary invoices for funding approval.
Ineffective Pest Control Program in Shower Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live small flies and roaches in the only active shower room. Observations revealed a small fly on the door frame and multiple live roaches and flies in the shower room. Interviews with staff and residents confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' personal rooms. The pest control log indicated sightings of roaches on several occasions, but entries were sparse and did not reflect the ongoing issue. The contracted pest control company had visited the facility and treated for various pests, but the problem persisted. Staff interviews revealed a lack of consistent documentation of pest sightings in the pest control log, which was supposed to guide pest control efforts. The Maintenance Supervisor and other staff acknowledged the issue and the potential impact on residents' quality of life, but there was no evidence of a comprehensive or effective response to the pest problem.
Failure to Maintain Resident Dignity Due to Lack of Privacy Covers
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents by not providing privacy covers for their catheter bags. Observations revealed that the catheter bags of these residents were left uncovered and visible from the doorways, which could lead to embarrassment and low self-esteem for the residents. This issue was identified during multiple observations over two days, where the catheter bags were consistently found without privacy covers. Resident #49, a male with a history of cerebral infarction, hemiplegia, and severe cognitive impairment, required extensive assistance with daily activities and had an indwelling catheter. Similarly, Resident #57, a male with chronic health conditions and cognitive intactness, was completely dependent on assistance and used an external catheter. Both residents' care plans included interventions to maintain their dignity and prevent catheter-related issues, yet the lack of privacy covers was not addressed. Interviews with staff, including CNAs and the DON, highlighted a lack of awareness and communication regarding the absence of privacy covers. Staff acknowledged the importance of privacy covers for maintaining resident dignity but were unaware of any shortages or missing covers. The facility's policy emphasized the importance of promoting resident dignity and privacy, yet this was not upheld in practice, as evidenced by the observations and staff interviews.
Failure to Notify Physician of Abnormal Keppra Levels
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for a resident taking Keppra, an antiseizure medication. The resident, who had a seizure disorder and moderate cognitive impairment, had a Keppra level that was out of the normal range on a specific date. Despite the facility's policy requiring prompt notification of high or toxic medication levels, the abnormal result was not communicated to the physician. Interviews revealed that the lab results were not flagged in the electronic medical record system, leading to the oversight. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapse, noting that the results were available in the electronic medical records and should have been communicated during shift reports. The facility's policy stated that nurses should notify physicians of high or toxic levels promptly, but this was not done. The physician indicated that routine monitoring of Keppra levels was not necessary unless the resident showed symptoms, but expected all lab results to be reported. The failure to notify the physician could result in the physician not being fully aware of the resident's clinical condition.
Facility Fails to Prevent Resident Elopement Leading to Arrest and Hospitalization
Penalty
Summary
The facility failed to prevent the elopement of two residents, leading to significant incidents. The first resident, diagnosed with dementia and other conditions, was able to leave the facility without supervision due to inadequate monitoring and access to the door code. Despite being assessed as a low risk for wandering, the resident left the facility and was later arrested for obstructing a train. The facility's failure to properly supervise and restrict access to the door code contributed to this incident. The second resident, also with cognitive impairments, repeatedly attempted to leave the facility and was eventually successful. Despite wearing a wander guard, the resident managed to exit the facility and was found at a transfer station, having suffered a stroke. The facility's inability to effectively monitor and prevent the resident's elopement, despite clear signs of exit-seeking behavior, resulted in the resident's hospitalization. Both incidents highlight the facility's failure to ensure adequate supervision and security measures for residents at risk of elopement. The lack of proper monitoring, failure to restrict access to door codes, and insufficient response to residents' exit-seeking behaviors were significant factors leading to these deficiencies.
Failure to Prevent Resident Elopement and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect, resulting in two residents eloping from the facility. The first resident, diagnosed with dementia and moderate cognitive impairment, was able to leave the facility without supervision. Despite being assessed as a low risk for wandering, the resident had access to the door code, which was shared by another resident. The resident left the facility unnoticed and was later arrested for obstructing a train. The facility's failure to conduct proper monitoring and ensure the resident's safety led to this incident. The second resident, also diagnosed with dementia and wearing a wander guard, repeatedly attempted to leave the facility. Despite being on 15-minute checks, the resident managed to elope and was found at a transfer station, having suffered a stroke. The facility's staff did not perform the required checks, and the wander guard system failed to prevent the resident from leaving. The resident's elopement and subsequent medical emergency highlight the facility's inability to adequately supervise and protect residents at risk of wandering. Interviews with staff and record reviews revealed that the facility did not adhere to its protocols for monitoring residents at risk of elopement. Staff failed to conduct regular checks and did not ensure that wander guard devices were functioning correctly. The facility's lack of effective supervision and failure to follow established procedures contributed to the residents' elopements and the resulting adverse outcomes.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents, leading to incidents of elopement. The first resident, who had moderate cognitive impairment due to dementia, was able to leave the facility without being noticed. This resident had access to the door code, which was given by another resident, and left the facility to smoke off property. The resident was later found 3.5 miles away and was arrested for impeding a train. Despite having a low risk for wandering, the resident's elopement risk assessments did not account for the possibility of obtaining the door code from another resident. The second resident, who was at high risk for wandering due to dementia, was wearing a wander guard device. However, the resident managed to leave the facility multiple times, including an incident where the resident was found lying on the ground at a transfer station after suffering a stroke. The resident's care plan included interventions to distract from wandering, but these measures were insufficient to prevent the resident from leaving the facility. The resident's behavior of packing belongings and expressing a desire to leave was noted, but the facility's interventions failed to effectively manage these behaviors. Both incidents highlight a lack of effective monitoring and supervision, as well as inadequate use of assistance devices like wander guards. The facility's failure to ensure that wander guards were functioning properly and to prevent residents from obtaining door codes contributed to these elopements. The facility's staff did not adequately monitor the residents' movements, and there was a lack of timely response to the residents' exit-seeking behaviors.
Failure to Provide Scheduled ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs) independently, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in two residents who did not receive their scheduled showers or bed baths as required. Resident #2, a cognitively intact male with a history of stroke and other medical conditions, reported not receiving bed baths according to his schedule due to staff shortages. He expressed dissatisfaction with the situation, having last received a bed bath on a specific date, despite his requests for assistance. Resident #1, who had moderate cognitive impairment and required substantial assistance with ADLs, also did not receive regular showers or bed baths. The facility's records showed a lack of documentation for showering tasks over the past 30 days, with only one bed bath recorded for Resident #1 during this period. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed a lack of awareness regarding the issue and confirmed that showers were not scheduled in the electronic care system, leading to a failure in documentation and task completion. The DON and other staff members acknowledged the oversight in scheduling and documenting showers, which resulted in residents not receiving the care they needed. The facility's policy on supporting ADLs emphasized the importance of providing appropriate care and services to maintain residents' hygiene and well-being. However, the failure to adhere to this policy and ensure proper documentation and scheduling of showers contributed to the deficiency observed by the surveyors.
Failure to Secure Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, a computer displaying wound care information for a resident was left unlocked and unattended at the nurse's station. This occurred while the Licensed Vocational Nurse (LVN) responsible for the computer walked away to check on the resident's wound status. During the time the computer was unattended, two residents and a visitor passed by the nurse's station, potentially exposing the resident's sensitive medical information. The resident involved was a cognitively intact male with a history of cerebral infarction, hemiplegia, Type II diabetes, atrial fibrillation, cellulitis, and a congenital pancreatic cyst. The LVN admitted to forgetting to lock the computer, acknowledging that this action violated the resident's privacy. The Director of Nursing (DON) and the Administrator were not initially aware of the incident but confirmed that it was against the facility's policy and expectations for staff to leave resident information unsecured.
Improper Storage of Medication in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had a packaged syringe labeled 0.9% sodium chloride and several alcohol swabs left on his bedside table. The resident, who was cognitively intact, reported that the facility nurses used the saline solution in his port and often left items in his room. This oversight was confirmed during an interview and observation with LVN A, who was unaware of the syringe being left in the resident's room. Further investigation revealed that LVN D, the resident's assigned nurse for the shift, had used the saline flush for the resident's central line before and after medication administration. However, LVN D did not recall leaving the flush in the room and acknowledged it was her responsibility to remove all medications and biologicals from the resident's room. The DON was informed of the incident and stated that it was against the facility's expectations for medication supplies to be left in a resident's room, as they could be contaminated or misused. The facility's policy on the storage of medications, revised in April 2007, mandates that drugs and biologicals be stored in a safe, secure, and orderly manner. The policy specifies that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. Despite this policy, the incident with the saline flush syringe indicates a lapse in adherence to these guidelines, potentially placing residents at risk of medication misuse.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in one of the resident rooms. During an observation and interview, a resident was found lying in bed with gnats flying off of him, indicating a pest issue in the room. The resident, who was nonverbal but able to answer yes and no questions, confirmed the presence of gnats and mentioned having reported the issue to staff, although he could not specify to whom. Despite the resident's report, the Licensed Vocational Nurse (LVN) and the Director of Maintenance (DOM) were unaware of the pest problem in the room. The facility's pest control program involved a pest control company visiting the facility monthly, with no reports of pests documented in the maintenance logs for the months reviewed. The DOM was responsible for pest control and expected staff to document pest concerns in the pest control binder or report them directly to him. However, the lack of awareness and documentation of the gnat issue in the resident's room suggests a breakdown in communication and reporting within the facility's pest control program.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted on a daily basis, as required, for one of the twenty-one days reviewed. On 05/17/24, observations at multiple times throughout the day revealed that the daily nursing staff posting near the dining room displayed the date of 05/16/24, indicating that it had not been updated. This oversight was confirmed during an interview with the Director of Nursing (DON), who was unaware that the posting had not been updated for the current day. The DON explained that the Assistant Director of Nursing (ADON) was responsible for updating the postings daily and typically provided staffing sheets in two-week increments at each pay period. However, the ADON had not provided the necessary sheets for the current pay period. The Administrator (ADMIN) also confirmed that the nurse staffing posting had not been updated for 05/17/24 and acknowledged that it should have been updated at the start of the day. The ADMIN stated that both the ADON and the receptionist were responsible for updating the daily nurse staffing posting. Despite the oversight, the ADMIN believed that residents were not affected as they did not pay attention to the posting, but acknowledged that they would be misinformed if the post was not updated daily. A related policy was requested from the ADMIN but was not provided before the exit.
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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.
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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) |
|---|---|---|---|---|
| Brentwood Place Three | 0 mi | ★★★★★ | 14 | 1 |
| Brentwood Place One | 0 mi | ★★★★★ | 3 | 0 |
| Brentwood Place Two | 0 mi | ★★★★★ | 10 | 0 |
| Brentwood Place Four | 0 mi | ★★★★★ | 1 | 0 |
| Carrollton Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 10 | 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.