Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Giles Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Missing grievance tracking records were identified when the grievance binder reviewed did not contain documentation of grievances for the period reviewed. The DON stated verbal concerns were reported to the Administrator, who was responsible for overseeing, tracking, and maintaining grievance records. The Administrator stated the grievance tracking system was missing, she kept personal notes but not the grievance forms needed to show how complaints were addressed and tracked, and the SW typically completed grievance tracking but was absent.
Failure to include hospice in a resident’s care planning after a significant change in condition. A resident with advanced cognitive impairment, diabetes, dementia, mood disorder, anxiety, insomnia, and hospice/DNR orders was admitted to hospice for heart failure, but the facility did not notify the local hospice of the as-needed care plan meeting. The Hospice Nurse and Hospice DON stated hospice was not invited or present, while facility staff said the Receptionist was responsible for making the calls and that they were unsure whether the hospice had actually been contacted. The facility’s hospice policy and agreement required a coordinated plan of care with hospice participation.
Respiratory care was not provided safely for several residents receiving oxygen or nebulizer treatment. A resident with respiratory failure had a nebulizer left uncovered on the nightstand, another resident with asthma had an uncovered nebulizer mask left on top of the machine, and two residents with oxygen orders were observed using concentrators with dirty filters. The DON and Administrator stated that nebulizer and oxygen equipment should be properly sanitized, bagged, and stored when not in use.
Medication carts contained multiple storage and labeling problems, including undated blood glucose strips and liquid protein, liquid meds with dried drippings, dusty drawers, resident personal items, discontinued meds, and opened items stored inappropriately. Staff also left a dixie cup with leftover medication and a tongue depressor at a resident’s bedside, and the resident had severe cognitive impairment with a BIMS of 0. The facility stated staff had been trained on dating opened products and removing discontinued items, but no specific policy for leftover med disposal was provided.
Food Storage and Ice Machine Sanitation Deficiencies: The facility failed to keep dry storage and refrigerated food items clean, properly dated, and properly sealed. Surveyors observed cereal containers with food particles, opened and undated bags and containers, greasy lids, dried drippings on bottles, and cracked lids on multiple food items. The ice machine also had visible white calcium build-up and white particles, and the cleaning schedule did not include the ice machine.
Required postings listing State agencies and advocacy groups, including the State Survey Agency complaint number and statement that residents may file a complaint, were only posted in one hallway and not throughout the building. In a resident interview, most residents said they did not know how to contact the State Survey Agency, and the admin confirmed the information was posted only in the 300 hall with no policy for required postings.
Failure to document and track a resident grievance: A resident with dementia and mild cognitive impairment reported that a medication aide was rude and did not assist her back to bed after repeated requests. The RP verbally notified the DON, but the concern was not documented as a grievance, and the DON and administrator acknowledged there was no supporting documentation even though the facility grievance policy requires prompt resolution and tracking by the grievance official.
Care Plan Did Not Include Nebulizer Intervention: A resident with asthma and altered respiratory status had an active order for ipratropium-albuterol nebulizer solution, but the care plan only addressed oxygen and did not include the nebulizer treatment as an intervention. The MDS nurse, DON, and Administrator all stated the care plan should have reflected the nebulizer use so staff would know it was part of the resident's care.
The facility failed to maintain proper nail care for three residents who needed staff help with ADLs. One resident with CVA, hemiplegia, and contractures had long fingernails with debris and said he had asked staff to trim them but had not been assisted. Two other residents with cognitive and mobility impairments also had long, dirty fingernails, and one of them additionally had long toenails. Care plans and staff interviews confirmed that nail care was part of routine resident hygiene and staff responsibility.
Controlled Substance Documentation Error: The facility failed to ensure accurate pharmaceutical services for 3 of 4 med carts reviewed. On Medication Cart 200 Hall, an LVN administered Morphine oral syringe but did not sign the Individual Control Record at the time of administration, and later stated she forgot to document it. The Compliance Nurse said licensed staff had just been retrained on signing out controlled substances when administered, and the facility policy required immediate entry of the date, time, amount, and nurse signature on the accountability record.
Two residents experienced dignity-related concerns and alleged neglect that were not properly reported to HHSC or documented as investigated. In one case, a resident with dementia and DM was found by family to be wearing two briefs, one soiled with urine and feces, after staff had already changed her, and staff later acknowledged that double briefing had occurred. In the other case, a resident with acute kidney injury and DM allegedly had a nurse respond to a call light, state she did not speak Spanish, and leave without providing care or sending another staff member. Multiple staff, including CNAs, an LVN, and RNs, described such actions as abuse, neglect, or negligence, and facility policy and a provider letter required all abuse/neglect allegations to be reported to the administrator and to HHSC within specified time frames. The DON and Administrator acknowledged that these family-reported events met the definition of abuse or neglect and warranted investigation, yet there was no written investigation for either allegation and neither was reported to HHSC, constituting a failure to protect resident dignity and comply with abuse/neglect reporting requirements.
Two residents’ allegations of abuse and neglect were not reported to the state or properly investigated. In one case, a resident with dementia and diabetes was found by family to be wearing two briefs, one soiled with urine and feces, after staff had already changed her; staff later acknowledged double briefing and multiple staff described this practice as abuse, neglect, or negligence. In the other case, a resident with acute kidney injury and diabetes alleged that a nurse responded to her call light, stated she did not speak Spanish, and left without providing care or sending another staff member. Although facility policy and state guidance required reporting all abuse and neglect allegations to HHSC within 24 hours and conducting internal investigations, leadership acknowledged there was no written investigation for either allegation and confirmed that these incidents were not reported to the state, while the administrator stated she did not believe they constituted abuse or neglect.
A resident with dementia and incontinence was found to be wearing two briefs, one of which was soiled with urine and feces, after a family member reported a strong odor and requested assistance. The family later presented a photo showing the resident double briefed and the bed soiled with urine and feces. Staff interviews confirmed that a CNA admitted to double briefing the resident, and multiple staff, including CNAs, the Treatment Nurse, an LVN, and the DON, stated that double briefing is not acceptable, is considered abuse, neglect, or negligence, and poses infection control concerns such as risk for UTIs and skin breakdown. Despite this, the ADON reported that the CNA was not suspended and the allegation was not investigated, contrary to the facility’s abuse/neglect policy and perineal care procedures.
A resident who was cognitively intact and dependent on ADLs received perineal care from a CNA who failed to follow the facility’s infection control and perineal care policies. During incontinent care, the CNA cleansed the resident’s perineal area, discarded soiled wipes and the brief, then wiped her gloved hands with a clean wipe and, without changing gloves or performing hand hygiene, applied a clean brief and repositioned the resident. In interviews, the CNA acknowledged this was not in accordance with protocol, while an LVN, an RN, and the DON all confirmed that staff were required to perform hand hygiene and change gloves after disposing of contaminated supplies, as outlined in the facility’s infection control plan and perineal care policy.
A resident with a terminal brain condition was admitted from a hospital on hospice with one family member documented as responsible party, while another family member was listed as next of kin on PASRR paperwork. The facility relied on existing hospice documents and its internal system, which named the first family member as representative, and did not review conflicting records or ask the resident whom he wanted to represent him. The resident, who was documented as alert and oriented with moderate cognitive impairment, told staff he did not want hospice and wanted a different family member to be his responsible party, but the facility continued to recognize the originally listed family member as the representative without consulting the resident, contrary to its resident rights policy allowing residents to identify individuals to be included in care planning.
The facility failed to ensure that three residents had their call lights within reach, compromising their ability to call for assistance. A resident with severe cognitive impairment and a fall risk had her call light on the floor, while another resident's call light was clipped out of reach. A third resident had no call light in her room. Despite staff training, the facility lacked a specific policy on call light placement.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen management. One resident had a dusty oxygen concentrator filter, while another had an improperly stored oxygen tank without a warning sign. Staff interviews revealed a lack of adherence to safety protocols, posing potential fire hazards.
A facility failed to maintain a clean and safe environment, as evidenced by a brown, thick substance on the floor of a resident's room entryway. The resident, who was cognitively intact and had a history of obsessive-compulsive disorder, muscle atrophy, and dementia, reported discomfort with the uncleanliness. Interviews with the Administrator and DON revealed that the facility's cleaning process involved housekeeping and rounds by nurses and CNAs, but staff failed to monitor the resident's room closely, leading to potential risks such as falls and pest attraction.
A medication aide in an LTC facility failed to follow infection control procedures by not wearing gloves while applying a lidocaine patch to a resident with severe cognitive impairment. Despite being trained to wear gloves, the aide found it difficult to apply the patch with them. The facility's policy requires gloves to prevent infection and medication absorption by staff.
A resident was found with a dixie cup containing Zinc Oxide pomade at their bedside, improperly left there by staff after application. The resident, who was cognitively intact and at risk of pressure ulcers, required the ointment for a sacral ulcer. Staff interviews revealed a lack of adherence to medication disposal protocols, posing risks of infection and misuse by other residents. The facility lacked a specific policy for supervising and disposing of medications.
The facility failed to follow professional standards for food service safety, as observed during a kitchen tour. Four oil containers were not labeled or dated, and a container of pork in the fridge had a ripped foil cover. The Director of Food and Nutrition acknowledged these issues, stating that all food items should be dated and labeled, and improperly sealed food could lead to contamination.
A resident with complex medical conditions, including dementia and morbid obesity, experienced a significant change in condition with a newly diagnosed DVT and severe weight loss. The facility failed to develop a comprehensive care plan addressing these issues, despite policies requiring updates for significant changes. Interviews revealed a lack of communication and follow-up among staff, contributing to the oversight in care planning.
The facility failed to properly dispose of razor blades in two shower rooms, leaving them outside of sharps containers, which posed a risk of injury. Additionally, a resident with dementia and a history of falls was found in bed without the required fall mat, contrary to their care plan. Staff interviews confirmed these oversights, highlighting deficiencies in accident hazard prevention and supervision.
A facility failed to implement a comprehensive care plan for a resident at risk of falls by not placing a required fall mat next to the bed. The resident, with a history of dementia and repeated falls, was found without the mat, which was instead leaning against a dresser. Staff interviews confirmed the oversight, highlighting a lapse in following the care plan designed to minimize injury risk.
A resident's care plan inaccurately documented the need for a mechanical lift for transfers, despite the resident requiring only moderate assistance. This error was due to outdated information following the resident's recovery from an ankle fracture. The facility's staff, including the Director of Therapy Services and the Administrator, confirmed the oversight, which was attributed to staff changes in the MDS department.
Missing Grievance Tracking Records
Penalty
Summary
The facility failed to maintain evidence demonstrating the results of grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed. During observation and record review on 05/07/2026 at approximately 1:30 PM, the grievance binder provided did not contain documentation of grievances from 04/14/26 through 05/08/26. During interviews, the DON stated that verbal concerns or complaints were reported to the Administrator in accordance with the facility grievance process, and that she investigated concerns related to the nursing department and reported findings to the Administrator. The DON stated the Administrator was responsible for overseeing, tracking, and maintaining grievance records. The Administrator stated she was responsible for maintaining grievance records, but the grievance tracking system was missing. She stated she maintained personal notes regarding concerns, but did not maintain the grievance forms needed to show how complaints were addressed and tracked. The Administrator also stated the SW typically completed grievance tracking, but due to the absence of an SW she had been overseeing the process and the lack of tracking was an oversight.
Failure to Notify Hospice of Care Plan Meeting for Resident with Significant Change
Penalty
Summary
The facility failed to follow its written hospice agreement and hospice services policy for a resident who had a significant change in condition and was admitted to hospice for heart failure. Resident #2 was a [AGE]-year-old female with diagnoses including type 2 diabetes, vascular dementia, unspecified dementia, mood disorder due to a physiological condition, anxiety disorder, and insomnia. Her significant change MDS showed severely impaired cognition with a BIMS score of 3, inability to recall or make daily decisions, and disorganized thinking. Her care plan identified that she had a terminal prognosis and/or was receiving hospice services under the local hospice, and physician orders included DNR/Hospice. The record and interviews showed that when Resident #2 was admitted to hospice, the facility did not notify the local hospice agency of the as-needed care plan meeting related to her significant change in condition. The Hospice Nurse stated she was not asked to attend and did not attend a care plan meeting for Resident #2 when she was admitted to hospice. The Hospice DON stated the local hospice did not have any care plan meetings with the facility for Resident #2 and was not invited to any care meetings. The MDS Nurse stated care plan meetings were done quarterly, on request, and as needed, and acknowledged that the local hospice had not been attending the care plan meetings. Facility staff identified that the Receptionist was responsible for calling the local hospice for care plan meetings, but multiple staff members stated they were not sure who ensured those calls were actually made. The Administrator stated she received an email with resident names and care plan meeting information from the Receptionist, and that the Receptionist called the local hospice so they could attend and coordinate care. The facility’s hospice policy required a coordinated plan of care reflecting hospice participation, and the hospice agreement stated the plan of care would be developed in full consultation with both hospice and the facility and collaboratively coordinated, evaluated, and modified on an ongoing basis.
Respiratory Equipment Left Unstored or Unclean During Use
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents who were receiving oxygen therapy or nebulizer treatment. Surveyors observed that Resident #2, who had diagnoses including acute and chronic respiratory failure with hypoxia, dyspnea, and dependence on supplemental oxygen, had a nebulizer sitting on the nightstand next to the bed and it was not bagged or stored when not in use. Resident #2 stated he had removed the nebulizer earlier in the day and left it on the nightstand to use later, and he reported that staff had not cleaned or stored it. The resident’s care plan directed staff to monitor for respiratory distress and to assist with oxygen equipment, including proper positioning, use of delivery devices, and monitoring effectiveness. Resident #46 had an active order for Ipratropium-Albuterol inhalation solution for shortness of breath and a diagnosis of mild persistent asthma with acute exacerbation. During observation, a nebulizer mask that was not in use was found uncovered on top of the nebulizer machine while the resident was not in the room. The resident’s care plan identified altered respiratory status and shortness of breath, but the observed nebulizer equipment was left exposed rather than stored. Resident #62 and Resident #79 both had active oxygen orders for 2 liters per minute via nasal cannula and were observed with oxygen concentrator machines in use that had dirty oxygen filters. Resident #62 had a diagnosis of heart failure and severe cognitive impairment, and Resident #79 had chronic respiratory failure with hypoxia and moderate cognitive impairment. The observations showed the concentrator filters were not clean while the equipment was being used in each resident’s room.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to provide safe and secure storage of medications in multiple medication carts on the E, B, and C halls. During observation and interview, surveyors found two bottles of blood glucose strips that were not dated when opened, even though the bottle label directed use within 6 months after first opening or before the expiration date. In the same cart, a bottle of Milk of Magnesia had dried drippings on the side of the bottle, and dried drippings were also present on the bottom of the drawer where medication bottles were stored. The LVN stated staff had been trained to date opened bottles and to clean liquid medication bottles after each use, and that all nurses were responsible for keeping the carts clean. In the 300 Hall medication cart, surveyors observed personal items stored in the cart, including air pods, dollar bills, coins, an upper denture in a plastic glove, and a coin purse. Five bottles of eye drops were stored together in a small plastic container after being removed from their boxes. The cart also contained bottles of Iron Supplement Liquid, Geri-Tussin, and Milk of Magnesia with dried drippings on the sides, and an open plastic bag in the bottom drawer containing a can of air freshener, a perfume bottle, chap stick, deodorant, and other personal care products removed from residents' rooms. Another bag contained over-the-counter medications. The LVN stated these items had been removed from residents' rooms and were being stored in the medication cart. Surveyors also found an opened bottle of Nystatin Topical Powder without a cap and with white residual on the bottle, and two large opened bags of lollipops stored in a bottom drawer. In the medication cart used by the Med Aides for the 200/300 Hall, surveyors found two small plastic containers with pudding that were not dated and were being used to mix crushed medications for administration. An opened bottle of Active Liquid Protein was not dated when opened, despite the label stating a 3-month shelf life from the date opened. A bottle of Valproic Acid Solution and a bottle of Lactulose had dried drippings on the sides, and the drawer containing Metformin 500 mg and two bottles of Galantamine ER was dusty with particles on the bottom. The Med Aide stated the drawer contained discontinued medications stored in the cart. Surveyors also found a medication box containing Fluticasone Propionate Nasal Spray with part of the pharmacy label torn off. The Compliance Nurse stated staff had been trained to date nutritional supplement bottles and blood glucose strip bottles when opened, and to remove discontinued medications and not store resident personal items in medication carts, but the facility did not provide the requested policy on medication storage before exit. The report also documented an event involving Resident #66, a female with dementia, muscle weakness, abnormal gait, cognitive communication deficit, and a BIMS score of 0 indicating severe cognitive impairment. Her care plan included staff administering medications as ordered and monitoring effectiveness and side effects. During observation, a dixie cup with leftover medication and a tongue depressor was left at the resident's bedside, exposed and within reach of other residents. The resident was unable to identify the medication when asked. Staff interviews confirmed the cup likely contained residual medication, that it should not have been left unattended in the room, and that the staff member administering the medication was responsible for disposing of any remaining medication. The Corporate Nurse stated that leaving leftover medication unattended in a resident's room was not acceptable practice and that the facility did not have a specific policy addressing disposal of leftover medications.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the kitchen dry storage room and refrigerator. During observation, multiple food containers and items were found with food particles, grease build-up, dried drippings, and cracked lids. Items observed included clear plastic containers holding breakfast cereal that were not dated and had cereal particles in the bottom, a disposable plate with cooked eggs, beans, bacon, and bread covered with a napkin and stored on top of metal food cans, and seashell pasta stored in a tied plastic bag that was not dated. Additional observations included opened bags of corn chips, cinnamon sticks, cinnamon sugar, roasted chicken gravy, and crushed corn that were not sealed and/or not dated when opened, as well as a large container of chocolate fudge frosting with a cracked lid and a large plastic oil container with oil dripping down the side. In the refrigerator, a plastic bottle of chocolate syrup dated as opened 3/12/26 had dried drippings on the side, a bottle containing tomato paste had dried drippings, a plastic syrup dispenser dated 3/05/26 had dried dripping on the lid and below the handle, and a large container of cottage cheese dated 2/02/26 had a cracked lid. The ice machine also had white calcium build-up on the front below the ice maker and around the edges of the bin door, with white particles present. The Dietary Supervisor stated they had attempted to remove the calcium build-up but were unable to do so, and the cleaning schedules for April 2026 did not list the ice machine.
Required State Agency Complaint Postings Not Accessible Throughout Facility
Penalty
Summary
The facility failed to post, in a form and manner accessible and understandable to residents and resident representatives, a list of names, addresses, and telephone numbers for pertinent State agencies and advocacy groups, including the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Surveyors observed that the required posting, including the HHSC complaint number and the statement that residents may file a complaint with the State Survey Agency, was posted only on the wall of the 300 hall. During the observation, there were no such postings on the 100, 200, or 400 halls. In a confidential group interview, 7 of 9 residents stated they did not know how to file a complaint or contact the State Survey Agency, and they said the only number they knew was the administrator's number because it was posted in all hallways. One resident stated she had seen the State Survey Agency number posted in the 300 hallway but rarely went there unless going to the activities room. The administrator confirmed that the State Survey Agency number was posted only in the 300 hallway and that there was no policy regarding required postings.
Failure to Document and Track Resident Grievance
Penalty
Summary
The facility did not ensure prompt efforts were made to document and resolve a grievance for one resident regarding a complaint about customer service. Resident #65 was an elderly female with dementia and mild cognitive impairment, and her care plan noted impaired cognitive function and interventions for discussing concerns with the resident and family/caregivers. According to the resident’s responsible party, on 03/30/2026 the resident called to report that a medication aide had not helped her get back into bed and had walked away after being asked multiple times for assistance. The responsible party stated he came to the facility that day and verbally informed the DON of the concern, but was not told to file a grievance and was told the DON would handle it. The DON stated she may have spoken with the responsible party about removing the medication aide from the resident’s care, but she could not recall and acknowledged the concern was not documented. She stated she thought it was resolved and that a grievance form should have been completed to ensure the issue was addressed and supported by documentation. The administrator stated she learned of the situation through a corporate complaint hotline and an email from corporate regarding the medication aide refusing to provide care, and she confirmed there was no supporting documentation. Review of the facility grievance policy stated the facility must make prompt efforts to resolve grievances and that the grievance official will oversee, track, and issue written decisions.
Care Plan Did Not Include Nebulizer Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #46, a female resident with an original admission date of 12/28/2023 and a readmission date of 04/27/2024. Her record showed a history and physical dated 12/01/2025 with a diagnosis of mild persistent asthma with acute exacerbation, and a Quarterly MDS assessment with a BIMS score of 15 indicating intact cognitive function. Her active physician order dated 08/15/2025 included ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml to be inhaled orally 1 application as needed. Review of the care plan revised 02/25/2026 showed that Resident #46 had altered respiratory status, difficulty breathing, and shortness of breath, but the interventions did not address the nebulizer treatment and instead stated to provide oxygen as ordered. During interview, the MDS nurse stated the care plan should mention the nebulizer treatment because it was one of the interventions being provided to the resident. The DON also stated the care plan should have been updated to reflect the nebulizer treatment, and the Administrator stated the use of a nebulizer treatment needed to be addressed in the care plan so all staff knew about its use for the resident's care.
Failure to Maintain Resident Fingernails and Toenails
Penalty
Summary
The facility failed to provide proper foot care and nail care for three residents who required assistance with ADLs. The deficiency involved Resident #29, Resident #57, and Resident #93, all of whom had documented functional limitations and needed staff help with personal hygiene. The report states that the facility did not ensure these residents had clean, properly maintained fingernails, and for Resident #93, toenails were also not maintained appropriately. Resident #29 had a history of CVA, left-sided hemiplegia, contractures, and muscle wasting, and was wheelchair bound with reduced strength and continued need for assistance with mobility and ADLs. His MDS showed he required substantial/maximal assistance with dressing and hygiene, and his care plan identified the need for staff assistance with ADLs. During observation, his fingernails on both hands were about one and a half centimeters long with dark and yellow debris under them, and his left hand was contracted with the nails touching his palm. He stated he did not like his fingernails long and had asked staff to trim them, but he had not been assisted. Resident #57 had osteoarthritis, limited mobility, and an ADL self-care deficit related to Alzheimer’s disease and a history of falls. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. During observation, her fingernails were about one centimeter long on both hands, and she was unable to voice whether she wanted them trimmed. Resident #93 had a history of CVA with residual left-sided weakness, a BIMS score of 12, and an ADL self-care deficit related to cerebral infarction with left hemiparesis/hemiplegia, contractures, and lack of coordination. Her care plan indicated she required one staff member’s participation with personal hygiene and oral care. During observation, her fingernails on the right hand were about one centimeter long with dark debris under and on the nails, and both toenails were about 1.5 centimeters long. She stated she would like her nails trimmed and that no one had asked her if she wanted them trimmed.
Controlled Substance Documentation Error
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and safe and secure storage of medications for 3 of 4 medication carts reviewed. During an observation and interview on 4/13/26 at 10:49 P.M. on Medication Cart 200 Hall, LVN F stated that she had administered Morphine 10 mg/0.2 ml oral syringe at 10:00 a.m. and forgot to sign the medication as given on the Individual Control Record. She also stated that staff had been trained to immediately sign out controlled substances when removed from the medication cart. During an interview on 4/13/26 at 12:00 p.m., the facility's Compliance Nurse stated that licensed staff had just been retrained on signing out controlled substances when a controlled medication is administered by the licensed nurse giving the medication. The facility's undated Medication Administration policy stated that controlled substances are subject to special handling, storage, disposal, and record keeping, and that when a controlled medication is administered, the licensed nurse administering it must immediately enter the date and time of administration, amount administered, and signature on the accountability record after the medication is actually administered.
Failure to Ensure Resident Dignity and Report Allegations of Abuse/Neglect
Penalty
Summary
The deficiency involves the facility’s failure to treat two residents with respect and dignity and to care for them in a manner that promotes or enhances their quality of life, as well as the failure to report allegations of abuse/neglect to HHSC as required. For the first resident, an elderly female with Alzheimer’s disease, diabetes mellitus II, and a history of falls, the resident’s family member reported that on a Saturday morning he noticed a strong odor of urine and feces. He requested assistance from nursing staff, waited outside while her brief was changed, and when he returned, the room still smelled strongly of urine and feces. He then requested further assistance from the nurse on the floor, and it was discovered that the resident was wearing two briefs, with one brief soiled with urine and feces. The family member later attended a care plan meeting with the social worker, treatment nurse, IDT, and facility administration, during which he showed a picture of the resident being double briefed and stated the bed was soiled with feces and urine. Staff interviews confirmed that double briefing was not an acceptable practice and was considered by multiple staff members to be abuse, neglect, negligence, or a dignity issue, with associated risks such as skin breakdown, infection, and UTIs. The treatment nurse stated he was notified of the family member’s allegation on a Monday and performed a skin assessment on the resident, and he acknowledged that the resident was unable to communicate what had happened and that the family member had witnessed and alleged the double briefing. The ADON reported that she was notified by nursing staff that the resident had been double briefed, that she interviewed the CNA involved, and that the CNA admitted to double briefing the resident and apologized. The DON stated she was informed by the ADON of the family member’s allegation and knew that the CNA had been in-serviced for double briefing. Despite these acknowledgments, the DON stated there was no written documentation of an investigation into this allegation, and the Administrator stated that although she recalled the meeting and said an internal investigation was conducted, she did not have any documentation to provide to the surveyor. The Administrator also stated she did not believe this allegation was abuse or neglect and therefore did not report it to HHSC. For the second resident, an elderly female with acute kidney injury and diabetes mellitus, the facility’s grievance log documented a grievance from the resident’s family member alleging that on a prior night an unnamed nurse entered the resident’s room in response to a call light, stated “no [name] (no Spanish)” when spoken to by the resident in Spanish, and then left without providing assistance or sending another staff member to assist. Staff interviews indicated that failing to answer call lights or turning off call lights without meeting residents’ needs was considered abuse and neglect, and that all allegations of abuse and neglect were to be reported to the DON and Administrator so an investigation could be conducted. The DON stated that the allegations made by the families of both residents were allegations of abuse or neglect that warranted internal investigation, and that she and the Administrator were responsible for investigating such allegations. However, she acknowledged there was no written documentation of an investigation for this resident’s allegation, and that no staff were suspended. The Administrator stated that the grievance was investigated internally and that she spoke with assigned staff, who denied the allegation, but she had no documentation of the investigation to provide and did not consider the allegation to be abuse or neglect requiring reporting to HHSC. Record review of the facility’s Abuse/Neglect policy showed that facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property, or injury of unknown source to the facility administrator, and that the administrator or designee must report to HHSC all incidents that meet the criteria of the applicable provider letter, with non–serious bodily injury allegations to be reported within 24 hours. The provider letter supplied by the Administrator specified that abuse and neglect must be reported to HHSC immediately but not later than 24 hours after the incident or allegation occurs, and defined neglect as the failure of a caregiver to provide goods or services necessary to avoid physical or emotional harm, pain, or mental anguish. Despite these written requirements and staff recognition that the described conduct constituted abuse or neglect, the facility did not report either resident’s allegation to HHSC and did not maintain documented investigations of the allegations, resulting in a failure to honor the residents’ rights to dignity, self-determination, communication, and to exercise their rights, and a failure to comply with mandated abuse/neglect reporting and investigation procedures.
Failure to Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse and neglect, including injuries or mistreatment, to the State Survey Agency as required, and failure to conduct and document internal investigations for two residents. For the first resident, an older female with Alzheimer’s disease, diabetes mellitus II, and a history of falls, the resident’s family member reported that on a morning visit he smelled a strong odor of urine and feces. He requested assistance from nursing staff and waited outside while the resident’s brief was changed. After staff left, he re-entered the room and continued to smell urine and feces, prompting him to request further assistance from the nurse on the floor. It was then discovered that the resident was wearing two briefs, with one brief soiled with urine and feces. The family member later attended a care plan meeting with the social worker, treatment nurse, IDT, and administrator, during which the nursing staff acknowledged that the resident had been double briefed and stated it was done because the resident was a “heavy wetter.” Staff interviews confirmed that double briefing was not an acceptable practice and was considered by multiple staff members to be abuse, neglect, or negligence, with associated risks such as skin breakdown, infection, and dignity issues. The treatment nurse stated he was notified of the family member’s allegation on a Monday and completed a skin assessment with no changes noted, and he acknowledged that the resident was unable to communicate what had happened. The ADON reported that she was notified by nursing staff that the resident had been double briefed, interviewed the CNA involved, and that the CNA admitted to double briefing and apologized. The DON stated she was informed of the allegation by the ADON and knew the CNA was in-serviced for double briefing. However, the DON also stated there was no written documentation of an investigation for this allegation, and the ADON stated the allegation was not investigated. The administrator stated there was an internal investigation but could not provide any documentation to the surveyor and did not believe the allegation needed to be reported to the state. For the second resident, an older female with acute kidney injury and diabetes mellitus, a grievance was filed by the resident’s family member alleging that an unnamed nurse responded to the resident’s call light, stated “no Spanish” when addressed in Spanish by the resident, and left without providing assistance or sending another staff member to assist. The grievance documented that the resident alleged the nurse left without meeting her needs. The DON stated she had been on personal leave at the time but acknowledged that the allegation made by this resident’s family member was an allegation of abuse or neglect that warranted an internal investigation. She further stated there was no written documentation of an investigation for this allegation. The administrator reported that the grievance was investigated internally and that staff denied the allegation, but she was unable to provide any documentation of this investigation and did not consider the allegation to be abuse or neglect requiring reporting to the state. Record review of the facility’s abuse/neglect policy showed that employees must report all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source to the administrator, and that the administrator or designee must report to HHSC all incidents that meet the criteria of the applicable provider letter, including reporting allegations of abuse or neglect within 24 hours. The administrator provided a Long-Term Care Regulation Provider Letter stating that abuse and neglect must be reported to HHSC immediately, but not later than 24 hours after the incident or allegation occurs. Despite these written requirements, the DON confirmed that there was no written documentation of investigations for either resident’s allegations, and the administrator confirmed that these allegations were not reported to HHSC. This failure to report and to document investigations of allegations of abuse and neglect constituted the cited deficiency.
Failure to Provide Appropriate Incontinence Care and Prohibit Double Briefing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate incontinence care and services to prevent urinary tract infections for a resident who was incontinent of bladder. The resident was an elderly female with Alzheimer’s disease, Diabetes Mellitus II, and a history of falls. Her Quarterly MDS indicated that a BIMS was not completed because she was rarely or never understood, indicating significant cognitive impairment. Facility policy on perineal care required proper cleansing and glove changes, and the abuse/neglect policy stated that residents have the right to be free from abuse and neglect. On a specific date, the resident’s family member reported being present in the morning when he noticed a strong odor of urine and feces from the resident. He requested assistance from nursing staff and waited outside while the resident’s brief was changed. After staff left, he returned to the room and continued to smell urine and feces, prompting him to request further assistance from the nurse on the floor. It was then found that the resident had two briefs on, with one brief soiled with urine and feces. The family member later participated in a care plan meeting where a picture of the resident being double briefed, with a soiled bed showing feces and urine, was discussed. Interviews with staff confirmed that double briefing occurred and that it was not an acceptable practice. The ADON stated she interviewed CNA A, who admitted to double briefing the resident and apologized. Multiple staff members, including CNAs, the Treatment Nurse, LVN D, and the DON, stated that having residents in two briefs at once was not acceptable, described it as abuse, neglect, or negligence, and identified it as an infection control issue with potential for skin breakdown, skin infections, or UTIs. The Treatment Nurse recalled being notified of the allegation and performing a skin assessment with no changes noted, but the ADON acknowledged that CNA A was not suspended and that the allegation was not investigated, despite the facility’s abuse/neglect policy requiring protection of resident rights and response to such allegations.
Failure to Follow Hand Hygiene and Glove-Change Protocol During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent and perineal care for one resident. Resident #3 was an older female, cognitively intact with a BIMS score of 15, and had a medical history including muscle wasting and atrophy. Her care plan indicated she was dependent on ADLs and required toileting/brief changes with one-person assistance. During an observation of perineal care, CNA B used clean wipes to cleanse the resident’s groin and buttocks, discarding soiled wipes and the soiled brief into a trash can next to the bed. After disposing of the dirty wipes and brief, CNA B used a wipe to clean her gloved hands and then, without changing gloves or performing hand hygiene, applied a clean brief and covered the resident with sheets and a blanket before removing her gloves and lowering the bed. In subsequent interviews, CNA B acknowledged that facility protocol required hand hygiene after disposing of dirty briefs, wipes, and gloves, and before donning new gloves and touching clean supplies such as a new brief. She admitted she did not change her gloves after disposing of the dirty items and instead wiped her gloves with a clean wipe, stating this was not protocol but that she did it because the resident was “not that dirty,” and recognized that the resident’s clean areas were at risk of contamination from her dirty gloves. LVN D, RN E, and the DON each confirmed that nursing staff, including CNAs, were responsible for performing perineal care per facility protocol, which included hand hygiene and changing gloves after disposing of contaminated supplies, and that failure to do so was an infection control issue. Review of the facility’s Infection Control Plan and the Perineal Care Female policy showed requirements for implementing hand hygiene practices and changing gloves during perineal care, including changing gloves during the procedure and removing gloves and washing hands as part of closing steps, which were not followed in this instance.
Failure to Verify and Honor Resident’s Choice of Representative
Penalty
Summary
The deficiency involves the facility’s failure to establish and honor the resident’s choice of representative/responsible party. A male resident with a terminal diagnosis of senile degeneration of the brain was admitted from a hospital with hospice orders and documentation listing one family member (Family Member #2) as the responsible party. The face sheet and hospice paperwork identified Family Member #2 as the responsible party and signatory for hospice services, while the PASRR Level I screening listed a different family member (Family Member #3) as next of kin. The resident’s history and physical documented that he was alert and oriented to person, place, and situation, though with significant forgetfulness and impaired insight. A BIMS assessment later showed a score of 8, indicating moderate cognitive impairment, but the entry MDS initially had no BIMS score. Family Member #3 reported that the resident had been placed on hospice by Family Member #2 prior to transfer and that she was notified only after the fact. She stated that at the current facility the resident told staff he did not want Family Member #2 as his responsible party because she did not treat him well, and that he did not have a power of attorney. She further stated that the facility did not consult the resident or family about who he wanted as his representative and simply continued the same responsible party designation from the hospital, based on the fact that the resident had lived with Family Member #2 before admission. During a care plan meeting, Family Member #3 voiced that she believed the resident did not need hospice, but was told that Family Member #2 was the next of kin and remained the designated representative. The Administrator stated that the facility relied on the hospice paperwork and information from the hospice agency, both of which identified Family Member #2 as the representative, and that the facility did not review the PASRR documentation or ask the resident whom he wanted as his representative. The Social Worker stated she relied on the facility system, which listed Family Member #2 as the responsible party, and was not aware of a different next of kin. She also reported that a BIMS assessment had been requested to better gauge cognition, but therapy did not complete it because the resident was on hospice. The resident himself stated he did not know how he ended up at the facility under hospice, reported that Family Member #2 left him there and did not want him back home, and clearly expressed that he did not want hospice services and wanted Family Member #3 to be his responsible party. The facility’s resident rights policy stated that residents have the right to identify individuals or roles to be included in the planning process, but the facility did not obtain or act on the resident’s expressed preference for his representative.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, which is a critical component for resident safety and communication. Resident #41, a female with severe cognitive impairment and a risk for falls, was observed with her call light on the floor, out of reach, during two separate observations. Her care plan specifically required that her call light be within reach to mitigate her fall risk. Similarly, Resident #60, also with severe cognitive impairment and at risk for falls, had her call light clipped to a wall light cord behind her bed, making it inaccessible. Her care plan also mandated that her call light be within reach. Resident #250, who has severe cognitive impairment and impaired mobility, was found without a call light in her room, contrary to her care plan's requirements. Interviews with facility staff, including CNAs and the DON, revealed a general understanding that call lights should be within reach of residents to ensure they can call for assistance when needed. However, despite regular in-service training on the importance of call lights, the facility did not have a specific policy regarding their placement. The lack of accessible call lights for these residents could lead to significant delays in care and potential falls, as residents may attempt to move without assistance. The DON acknowledged the importance of call lights being within reach and the potential risks if they are not, yet the facility's practices did not consistently reflect this understanding. The absence of a specific policy on call light placement may have contributed to these deficiencies.
Deficiencies in Oxygen Management and Safety Protocols
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen management. Resident #20, who was diagnosed with respiratory failure and severe cognitive impairment, was observed with a dusty and unclean oxygen concentrator air filter. The facility's staff, including the LVN and DON, were unsure about the frequency of cleaning the filters, which depended on the manufacturer's recommendations. The central supply personnel noted that the filters were last cleaned in December 2024, and there was a lack of awareness about the risks associated with dirty filters. Resident #87, diagnosed with pulmonary embolism and acute respiratory failure, was found to have an oxygen tank improperly stored in his room without an oxygen sign posted outside. The tank was left open, allowing oxygen to escape, which posed a potential fire hazard. Interviews with various staff members, including LVNs, CNAs, and the DON, revealed a lack of adherence to safety protocols, such as posting oxygen signs and ensuring tanks were closed and stored properly. The staff acknowledged the risks of fire or explosion due to the improper handling of oxygen equipment. The facility's policy on oxygen administration required the placement of no smoking signs and proper storage of oxygen canisters, but these protocols were not followed. The Administrator and DON confirmed the necessity of these safety measures to prevent potential hazards. The failure to adhere to these protocols could lead to significant safety risks for residents and staff, as indicated by the observations and interviews conducted during the survey.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by the presence of a brown, thick substance on the floor of room 104's entryway. This deficiency was identified during an observation and interview with a resident who reported the spill, resembling maple syrup, at the entrance to his room. The resident, who was cognitively intact and had a history of obsessive-compulsive disorder, muscle atrophy, and dementia, expressed discomfort with the uncleanliness and speculated that the spill might have been caused by staff delivering breakfast. The resident also noted that staff sometimes delayed cleaning his room, contributing to his discomfort. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the facility's cleaning process involved housekeeping and rounds conducted by nurses and CNAs to ensure cleanliness. Both the Administrator and DON acknowledged the potential risks associated with the spill, including falls, resident discomfort, and pest attraction. The Administrator admitted that the facility staff failed to closely monitor the resident's room to ensure it was clean and sanitary, which could lead to a resident feeling depressed in a dirty environment. The facility's policy on infection control precautions emphasized the importance of cleaning and disinfecting resident rooms and equipment, but the failure to adhere to this policy resulted in the observed deficiency.
Infection Control Breach in Transdermal Patch Application
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of a medication aide who did not adhere to proper procedures when applying a transdermal patch to a resident. The resident, a female with severe cognitive impairment and a diagnosis of osteoarthritis of the hip, was prescribed a lidocaine 4% patch for pain relief. During an observation, the medication aide was seen removing the old patch and applying a new one without wearing gloves, which is against the facility's policy and infection control procedures. The medication aide admitted to not wearing gloves because she found it difficult to apply the patch with them on, despite being trained to do so. She acknowledged the importance of wearing gloves for infection control and to prevent medication absorption through her skin. The Director of Nursing confirmed that the procedure for applying transdermal medications includes wearing gloves to prevent infection and medication absorption by staff. The facility's policy also mandates the use of gloves or avoiding contact with the medication side of the patch to prevent absorption through the skin.
Improper Medication Management and Disposal
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, leading to a deficiency in medication management. Specifically, a resident was found with a dixie cup containing Zinc Oxide pomade and a tongue depressor at their bedside, which was exposed and within reach of other residents. This situation arose from the staff's practice of pouring a portion of the medication into a cup for application during peri care, but failing to discard the leftover medication as required by infection control protocols. The resident involved was a cognitively intact male with a history of cerebral palsy, neuromuscular dysfunction of the bladder, seizures, kidney failure, and a urinary tract infection. He was at risk of developing pressure ulcers and required assistance with activities of daily living and mobility. The care plan included the application of Zinc Oxide to a pressure ulcer on the sacrum, but the medication was improperly left at the bedside, posing a risk of misuse by other residents. Interviews with various staff members, including an RN, CNA, LVN, DON, and the Administrator, revealed a lack of adherence to proper medication disposal procedures. The staff acknowledged the potential risks of leaving medication at the bedside, such as infection control issues and the possibility of other residents ingesting or misapplying the medication. The facility did not have a specific policy addressing the supervision and disposal of medications, contributing to the deficiency.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Four containers of Pan & Grill frying oil in the dry food pantry were found to be neither labeled nor dated. The Director of Food and Nutrition acknowledged that the oil containers should have been dated and stated that they would be disposed of. Additionally, a metallic container labeled 'PORK' in the walk-in fridge was covered with foil that had a ripped opening, which the Director also acknowledged and stated would be covered properly. During an interview, the Director of Food and Nutrition explained that the procedure for receiving food items includes dating all items once they are received and out of the box, and that it is the responsibility of all kitchen staff to ensure this is done. The Director mentioned that undated or unlabeled food items are typically disposed of, as was the case with the oil containers. He expressed that there was no risk to residents from the undated oil but acknowledged that improperly sealed food could lead to contamination and foodborne illnesses, although he believed the pork was stored in a safe area.
Failure to Develop Comprehensive Care Plan for Resident with DVT and Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a significant change in condition due to a newly diagnosed deep vein thrombosis (DVT) and severe weight loss. The resident, a female with multiple complex medical conditions including dementia, morbid obesity, and catatonic schizophrenia, was admitted to the facility with a history of significant weight loss and was dependent on staff for all activities of daily living. Despite these conditions, the facility did not create a care plan addressing the resident's DVT or severe weight loss, which are critical aspects of her care. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The records showed that the resident had been diagnosed with a DVT in her right arm and was prescribed Xarelto, an anticoagulant, but this condition was not included in her care plan. Additionally, the resident experienced a significant weight loss over several months, yet there was no care plan to address this issue. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), Assistant Director of Nursing (ADON), Dietary Manager (DM), and the Primary Care Physician (PCP) revealed a lack of communication and follow-up regarding the resident's care needs, contributing to the oversight in care planning. The facility's policies required that any significant change in a resident's condition should be reflected in an updated care plan. However, the staff interviews indicated that the care planning process was not followed, with the ADON citing being overwhelmed with staff turnover as a reason for the oversight. The DM had communicated the resident's weight loss to the team, but there was no follow-up to ensure a care plan was developed. The PCP was aware of the resident's weight loss and DVT but was not informed about the lack of care planning. This lack of coordination and adherence to care planning protocols resulted in the resident not receiving a comprehensive care plan tailored to her needs.
Improper Disposal of Sharps and Fall Prevention Oversight
Penalty
Summary
The facility failed to ensure proper disposal of razor blades in two out of three shower rooms, specifically in the 100 hall and 200/300 hall shower rooms. During observations, disposable shaving razors were found outside of the sharps container, posing a risk of injury to residents and staff. The Director of Nursing (DON) acknowledged the issue, noting that the central supply was responsible for emptying the containers, and emphasized the potential risks of cuts and infections from improperly disposed sharps. Additionally, the facility did not adhere to the care plan for a resident identified as a fall risk. The resident, who has dementia, muscle weakness, and a history of falls, was observed in bed without the required fall mat in place. The mat was found leaning against a dresser, away from the resident's bed, contrary to the care plan's directive to have it in place at all times when the resident is in bed. Interviews with staff confirmed the oversight and highlighted the increased risk of injury due to the absence of the fall mat. The facility's policies and procedures, including the Discarding of Sharps policy, were not followed, leading to potential hazards. The DON and Administrator both recognized the importance of adhering to care plans and proper disposal procedures to prevent injuries. The failure to follow these protocols resulted in deficiencies related to accident hazards and inadequate supervision, as observed by the surveyors.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical and nursing needs. Specifically, the facility did not follow the care plan for a resident at risk of falls by failing to have a fall mat in place next to the bed while the resident was lying down. This deficiency was observed during a survey when the resident was found in bed without the required fall mat, which was instead leaning against a dresser approximately five feet away. The resident, who has a history of dementia, muscle weakness, and repeated falls, was assessed to require partial/moderate assistance with transfers and had experienced multiple falls since admission. Despite the care plan specifying the use of a floor mat to minimize injury risk, staff interviews revealed that the mat was not consistently placed as required. The CNA, LVN, DON, and Administrator all acknowledged the importance of following the care plan to prevent potential injuries, yet the mat was not in place, indicating a lapse in adherence to the care plan.
Inaccurate Transfer Method Documented in Resident's Care Plan
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the method of transfer documented in the care plan. The resident, who has severe cognitive impairment and requires moderate assistance for transfers, was inaccurately documented as needing a mechanical lift for transfers. This discrepancy was discovered during a review of the resident's care plan, which had not been updated to reflect the resident's current ability to bear weight and perform transfers with moderate assistance. Interviews with the Director of Therapy Services and the Director of Nursing confirmed that the resident's care plan was outdated and did not accurately represent the resident's current transfer needs. The inaccurate documentation stemmed from a previous condition where the resident required a mechanical lift due to an ankle fracture. However, after the fracture healed, the resident's transfer needs changed, but the care plan was not updated accordingly. The Director of Therapy Services and the Administrator acknowledged the oversight, attributing it to staff changes in the MDS department, which led to the failure to update the care plan. The facility's documentation policy emphasizes the importance of maintaining complete and accurate records, highlighting the deficiency in this case.
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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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Ventanas De Socorro | 1.9 mi | ★★★★★ | 24 | 0 |
| Oasis Nursing & Rehabilitation Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Pebble Creek Nursing Center | 4.2 mi | ★★★★★ | 10 | 0 |
| El Paso Health & Rehabilitation Center | 4.5 mi | ★★★★★ | 11 | 0 |
| Vista Hills Health Care Center | 5.4 mi | ★★★★★ | 16 | 1 |
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