Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Terrell Healthcare Center during CMS and state inspections, most recent first.
Failure to designate a qualified Infection Preventionist: The ADON stated she was overseeing infection control and logging, tracking, and trending infections, but she did not have the required certification and was still working on it. The MDS nurse said she had Infection Preventionist certification but no longer oversaw infection control, while the DON and Administrator acknowledged the ADON should have been certified to serve in that role.
Privacy and mail delivery deficiencies were identified when an LPN left a resident’s MAR unlocked and visible on a med cart while entering the resident’s room to remove an IV antibiotic, allowing others to pass by and view the resident’s information. The resident had wound infection, HF, stroke, and HTN, and was moderately cognitively impaired. The facility also did not ensure residents received mail on Saturdays, with residents reporting delays until Monday and staff giving inconsistent accounts of who was responsible for weekend mail distribution.
PASRR coordination and screening failures: A resident with schizophrenia had a positive PASRR evaluation, but no PCSP meeting was documented and the MDS Coordinator did not verify the reported refusal with the resident or local authority. Another resident with paranoid schizophrenia had recommended habilitation and independent living skills services, but the facility had no documentation of those visits. A third resident with bipolar disorder and PTSD had Medicaid eligibility established, but the local authority was not notified to start PASRR services. A fourth resident with PTSD had an inaccurate PASRR screening that omitted the PTSD diagnosis despite charted trauma history and triggers.
Catheter securement and indication deficiencies: A facility failed to keep two residents’ indwelling catheters properly secured, despite care plans and orders requiring leg strap placement each shift. One resident said the tubing had not been secured for weeks, and another said the missing securement device caused soreness at the stoma. The facility also maintained an indwelling catheter for a third resident without documenting an appropriate diagnosis or indication, and both the resident and RN said they did not know why the catheter was in place.
Surveyors found controlled meds stored unsecured in a refrigerator door, including Lorazepam and Morphine for two residents, and an open insulin pen on a med cart without an open date. They also found wound cleanser left in one resident’s room and triad, triple antibiotic ointment, and hydrocortisone cream stored in another resident’s bedside area. Staff and the DON acknowledged the storage and labeling problems during observation and interview.
Food Not Served at Palatable, Attractive, and Appetizing Temperatures: A resident meal service was observed with food that residents described as bland and warm, and the test tray was noted to be unattractive. The Dietary Mgr stated the pork chops could be warmer, the yams were bland, and the pudding could be cooler. The Administrator stated meals were expected to look appetizing, taste good, and be delivered hot, while temperature logs showed mixed item temps including cornbread at 114 degrees and pudding at 60 degrees.
Kitchen Food Safety and Sanitation Deficiencies: The dietary manager and other kitchen staff were observed without required hair restraints, including a hair net and beard cover, while the microwave had visible residue, the fryer grease was dark with burnt food particles, the juice nozzle had a black film, and expired shredded carrots were stored in the refrigerator. Interviews showed staff and the DON acknowledged the sanitation and food safety issues and stated they were responsible for maintaining clean equipment, proper hair restraints, and removing expired food.
A resident with an indwelling catheter, COPD, diabetes, and HTN was observed in bed with the catheter bag exposed and no privacy cover in place. Although the chart included an order for a privacy bag every shift and the MAR showed the order as signed, staff acknowledged the bag was not consistently reapplied and that the resident should have had it in place for dignity.
Failure to obtain informed consent for an antipsychotic medication before administration. A resident with major depressive disorder and hallucinations, who had intact cognition and a BIMS of 15, was ordered Olanzapine 5 mg BID for hallucinations and received it daily without a signed consent in the EMR at the time of review. A later-scanned consent form was dated after the medication had already been given, and the ED, DON, and Administrator stated consents were expected before administration.
A resident with dementia, depression, and muscle weakness was found in bed with her call light on the bedside table and not within reach. She said she usually had to holler out for help, and a CNA and the charge nurse confirmed the pull cord was too short for her to use. Her care plan directed staff to anticipate and meet her needs and keep the call light within reach, and facility leadership stated residents should always have a usable means to call staff.
MDS Incorrectly Coded Resident’s Primary Language: A resident with severe cognitive impairment and a documented Spanish language barrier was coded on the quarterly MDS as English speaking and not needing an interpreter. The care plan and facility records identified the resident as Spanish speaking, and the MDS Coordinator, Regional MDS Coordinator, DON, and Administrator all stated the assessment should have reflected Spanish as the primary language.
A CNA applied Triad hydrophilic wound dressing paste to a resident’s bilateral buttocks after catheter care, even though the resident’s care plan and order were for Triad to the sacrum and staff stated CNAs were not qualified to apply it. The resident had paraplegia, heart failure, urinary retention, major depressive disorder, and was cognitively intact with a BIMS of 15. Interviews with LVNs, the ADON, DON, and Administrator confirmed that Triad was a medication/prescription product that should be administered by nursing staff, not CNAs.
Failure to Provide Effective Communication Assistance: Two residents with Spanish as their primary language did not receive consistent communication support. One resident had severe cognitive impairment and the other was blind and required total ADL assistance, yet staff often relied on hand gestures, personal phones, or limited English/Spanish exchanges, and no communication device was observed in either room. The MDS, care plans, and staff interviews showed inconsistent identification and use of the facility’s tablet app and other language assistance tools.
A resident with cerebral palsy, TBI, and contractures did not have an ordered left wrist roll applied during multiple observations, even though the care plan and physician order required daily use for contracture prevention and management. The wrist roll was repeatedly found on the dresser instead of on the resident’s left wrist, and staff interviews showed confusion and inconsistent follow-through by CNAs, LVNs, the DOR, and the DON regarding application of the device.
Missing oxygen orders and dirty oxygen equipment: Two residents receiving oxygen lacked physician orders for the therapy, and one resident’s oxygen concentrator filter was repeatedly observed covered in gray matter. One resident with COPD had oxygen in use despite no order in the chart, while another resident with respiratory failure had oxygen in use without an order and without oxygen included on the care plan. The DON and Administrator stated staff were responsible for documenting oxygen orders and cleaning or changing oxygen equipment on a schedule.
A resident with PTSD, depression, anxiety, hallucinations, and intact cognition had documented trauma history and triggers such as loud noises, specific smells, restraints, and large crowds, but the baseline care plan listed no mental health needs, no behavioral concerns, and no PTSD interventions. The resident also had no orders for monitoring traumatic stress behaviors or triggers, despite staff acknowledging that trauma-informed care was expected and that the resident did trigger for trauma-informed care.
The facility failed to properly document controlled meds awaiting disposal and failed to ensure narcotics in the hall 100 med room refrigerator were counted each shift. The DON said discontinued meds were placed in a locked cabinet for destruction, but one medication entry was left incomplete on the destruction log. Staff also reported not counting Lorazepam and Morphine stored in the refrigerator, and one LPN said the meds were known to be there but were not placed in the lock box. The DON and Administrator stated narcotics should be counted every shift and stored under double lock.
The facility failed to obtain ordered lab tests for two residents. One resident with a seizure disorder had an active Tegretol level order, but the last documented level was months earlier. Another resident with vitamin D deficiency had an active vitamin D order, but no drawn level was found in the EHR. The ADON stated she marked the orders as completed even though the labs had not been drawn, and said she should have contacted the lab and placed the requisitions in the lab book. The DON, Medical Director, and Administrator stated labs were expected to be drawn as ordered.
Failure to honor a resident’s food preference for double vegetables. A resident with intact cognition, malnutrition, and a physician order for extra vegetables received only one serving of vegetables at lunch even though the meal ticket listed extra vegetables. Staff, including an LPN and dietary staff, acknowledged the tray did not match the ticket and stated the preference was overlooked during meal service.
Failure to provide ordered double protein portion: A resident with severe protein-calorie malnutrition and a physician order for double protein received only a single pork chop at lunch, despite the meal ticket reflecting the correct order. Staff, including an LVN, dietary staff, the DON, and the Administrator, acknowledged the tray did not match the ticket and that the resident should have received two servings.
Hospice documentation and medication orders were not kept current or aligned. A cognitively intact resident with CKD stage 5 and HF was receiving hospice services, but the facility did not have the most current hospice POC, IDG reports, medication report, or physician orders in the chart. The hospice med list did not match the facility orders, with differences in acetaminophen route/dose and a missing bisacodyl order. The hospice PCM said hospice case managers were responsible for updating binders and communicating changes, while the DON said no one was currently monitoring ongoing orders and the Administrator identified the ADON and DON as responsible for keeping the binders current.
Dirty linen was not discarded properly during wound care for a resident with venous and arterial leg ulcers and PVD. An LVN removed wet towels from the resident’s leg and placed them on the resident’s dresser, where skin shedding was observed, instead of placing them in a plastic bag. The LVN, ADON, DON, and Administrator all acknowledged that the towels should have been bagged for disposal.
Surveyors observed a medication aide leaving a card of gabapentin 300 mg capsules on top of a 200-hall med cart while entering a resident's room, leaving the medication unattended and out of view in a hallway with residents present. In a separate instance, an LVN left a 200-hall nurse med cart unlocked and unattended with a vial of insulin lispro on top while inside a resident's room, with staff and residents nearby. Both staff acknowledged that medications should not be left unattended or on top of carts and that carts should be locked, while the DON and Administrator confirmed expectations and a facility policy requiring all drugs and biologicals to be stored in locked compartments and prohibiting unattended unlocked med carts.
Surveyors found that a resident with anxiety and heart failure did not consistently receive a prescribed TID antianxiety medication, despite the MAR showing it as given and multiple partially used medication cards remaining on the cart, and that another resident with depression and bipolar disorder had both an active sertraline 50 mg dose and a discontinued sertraline 100 mg dose still present on the medication cart. Staff interviews revealed that a medication aide denied missing doses, the DON had only verbally addressed the concern after the resident reported missed noon doses, and nursing staff gave conflicting accounts about communication and responsibility for removing discontinued medications, contrary to facility policies on medication administration and storage.
A resident with pneumonia and chronic respiratory failure was placed on droplet precautions per physician orders, with signage and PPE supplies outside the room, but the care plan did not address droplet precautions. A CNA entered the room without PPE and later removed PPE in the hallway instead of before exiting the room. A medication aide twice failed to use a face shield as required for droplet precautions and removed or retained PPE inappropriately while moving between the room and hallway and preparing medications. The DON and Administrator stated staff were expected to don mask, face shield, gown, and gloves before entry and remove PPE before exit, while the written IPCP lacked specific PPE guidance for droplet precautions and no droplet-specific policy was provided.
A resident with ESRD received in-house dialysis, but the facility did not document before-and-after assessments or maintain ongoing communication with the dialysis service for multiple treatments. RN, DON, and Admin interviews confirmed charge nurses were expected to complete dialysis communication forms before and after each treatment, and the facility’s dialysis protocol called for establishing dialysis days and implementing communication regarding the plan of care.
Medication administration errors exceeded the allowed rate, with 4 errors out of 30 opportunities. An MA failed to give one resident's psych and antidepressant meds during the observed pass as documented, and failed to give another resident's carvedilol with meals as ordered. The resident involved in the first error had schizophrenia and major depressive disorder, with intact cognition, and said the observed pass was the only time she received meds.
Medication labels did not match current orders for two residents, and medications and wound care items were left unsecured in a resident’s room. One resident’s famotidine, aripiprazole, and amantadine labels still reflected g-tube administration even though he was receiving meds by mouth, and another resident’s tamsulosin label still showed bedtime dosing even though it was being given in the morning. In addition, wound cleanser, Medi honey, and Fleet enemas were observed on a resident’s dresser, and staff stated these items should not have been left in the room.
Dietary staff failed to maintain current food handler certificates for 3 of 8 staff reviewed, including a cook and kitchen aides. Record review showed expired certificates on file for two staff and no current certificate for one staff member until after surveyor intervention. The Dietary Manager said the certificates should have been completed before staff started in the kitchen, and the Administrator said all kitchen staff were expected to have the certificate before it expired and before beginning work.
Food was not consistently palatable or served at an appetizing temperature during lunch. Residents reported bad taste, bland food, and meals that were not warm enough, and a sample tray observed by surveyors was only lukewarm; the Dietary Manager said he would not want to eat it if received on the halls. The DON stated food should have been delivered in a timely manner and hot when residents received it.
A facility failed to maintain infection control for three residents. A resident with shingles had contact precautions noted in the care plan, but the order did not specify the isolation type and the door sign did not identify the precautions or PPE. During incontinent care for a resident with quadriplegia and bowel incontinence, CNAs used improper wiping technique and changed gloves without hand hygiene. During a mechanical lift transfer for a resident on dialysis with enhanced barrier precautions, two CNAs assisted without PPE.
The facility failed to keep care plans current for three residents. One resident receiving hydroxyzine for anxiety had no care plan entry for the medication, one resident’s smoking status changed from supervised to unsupervised but the care plan was not updated, and one resident’s trach size changed from 7.0 to 6.0 without a corresponding care plan revision. The MDS Coordinator and DON acknowledged care plans should be updated when resident conditions or orders change.
A resident with cerebral palsy, convulsions, and shaken infant syndrome was totally dependent for all ADLs and had little or no activity involvement related to physical limitations. The quarterly MDS activity section was not completed because the resident was rarely or never understood and no family interview was done, and the AD stated she did not complete quarterly activity assessments. Observations showed the resident sitting alone in his room with cartoons playing on the TV, while staff reported he sometimes attended music or TV room activities and that he liked being read to but had no books.
Failure to Apply Ordered Left Wrist Roll for Contracture Management: A resident with cerebral palsy and significant contractures had an order to wear a left wrist roll daily or as tolerated for contracture prevention and management, but repeated observations found the device not in place. Staff interviews showed inconsistent awareness of the device, while nursing documentation on the TAR indicated it was applied. OT provided weekly passive ROM, and the DOR stated nursing was responsible for daily application of the hand roll.
A resident with ESRD, CHF, respiratory failure, and bipolar disorder was transferred with a mechanical lift without two staff present for the entire transfer. CNA M was observed lifting the resident alone, and CNA L entered later to help complete the transfer. The resident was totally dependent for several ADLs, had a BIMS score of 15, and his care plan required two staff for transfers. RN G, the DON, and the Administrator stated that mechanical lift transfers should always be done with two staff.
A resident with chronic respiratory failure and tracheostomy status was observed receiving oxygen at 5 L instead of the ordered 4 L, and the resident did not initially have an extra trach tube or Ambu bag in the room. Staff later confirmed the missing trach supplies, and the DON stated the resident should have had an Ambu bag, a smaller backup trach, and other trach equipment at bedside. The facility policy required a replacement trach tube and suction equipment to be available at the bedside at all times.
A resident with schizophrenia and major depressive disorder had escitalopram increased from 5 mg to 10 mg, but both doses were found on the med cart even though the 5 mg order had been discontinued. RNs stated discontinued meds should be removed from the cart, and the DON and Administrator confirmed that leaving them there could lead to med errors.
Smoking safety evaluations were not completed quarterly for two residents who smoked. One resident had dementia, diabetes, and HTN and was observed smoking outside while keeping his own supplies with him. Another resident had dementia, TBI, and seizures, had severe cognitive impairment, and was observed carrying an unlit cigarette and lighting it outside with a lighter from her pocket. The SW, DON, and Administrator stated the assessments were their responsibility and acknowledged they were being done yearly rather than at the required interval.
A resident with quadriplegia, mental illness, and TBI was identified as needing a specialized pressure-reducing mattress per PASRR recommendations, but the facility failed to submit the required NFSS form and did not provide the DME within the mandated timeframe. Staff interviews revealed gaps in PASRR training and the absence of a facility policy for PASRR coordination.
A staff member did not complete the required annual training on resident rights and facility responsibilities, as identified through record review and confirmed by the Administrator. Facility policy requires all staff to participate in annual in-service training on these topics.
The facility did not ensure that all staff completed required annual training on the Quality Assurance and Performance Improvement (QAPI) program, as three employees—a RN, a CNA, and a LVN—were found to have missed this mandatory training, contrary to facility policy.
A registered nurse did not complete the required annual compliance and ethics training, as identified through record review and staff interviews. Facility policy mandates annual in-service training on compliance and ethics for all staff, but this requirement was not met for one employee.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. During an interview, the ADON stated she was in charge of infection control but did not have the certificate to be the infection control preventionist, and she said she was working on obtaining her certification. The ADON also stated the MDS nurse had certification for infection control preventionist, but the MDS nurse said she did have her Infection Preventionist certification and no longer oversaw anything with infection control. The DON stated the MDS nurse had certification for infection preventionist, while the ADON was responsible for logging infections and tracking and trending infection control information, but was not certified and should have been certified as an infection preventionist. The Administrator stated he knew the ADON should have completed her certification to be the infection preventionist. Review of the ADON's personnel file showed she was hired on 02/01/26, and the facility policy stated the infection prevention and control program is coordinated and overseen by an infection prevention specialist.
Privacy and Mail Delivery Deficiencies
Penalty
Summary
The facility failed to protect Resident #19’s personal privacy and confidentiality of medical records when an LVN left the computer screen on top of the medication cart unlocked with the resident’s MAR clearly displayed. During observation, the LVN stepped away from the cart and entered the resident’s room to remove an IV antibiotic while unknown staff and residents were seen walking by the unlocked screen. The LVN stated she left the computer screen open because she was in a hurry and acknowledged she should have closed the MAR before entering the room, stating it was a HIPAA violation to keep it open where others could see the resident’s personal information. Resident #19 was a male admitted and re-admitted to the facility with diagnoses including wound infection, heart failure, stroke, and high blood pressure. His quarterly MDS indicated he sometimes understood and was sometimes understood by others, with a BIMS score of 10 showing moderate cognitive impairment. His care plan showed he was receiving IV medications related to wound infection, and physician orders included cefepime IV every 8 hours for infection until 04/12/2026. The facility also failed to ensure residents received mail promptly on Saturdays. In a confidential group interview, 8 residents stated they did not always receive their mail on Saturdays and had to wait until Monday when the Activity Director passed it out. Interviews with the Activity Director, Dietary Aides, the Business Office Manager, the DON, and the Administrator showed inconsistent handling of weekend mail, including mail being checked by dietary staff, held until Monday, or distributed by the Activity Director, and the Administrator stated there was not a system in place to ensure residents received mail on Saturdays.
PASRR coordination and screening failures
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority for residents identified through PASRR as having mental illness or related conditions. For one resident with schizophrenia and depression, the record showed a PASRR Level 1 screening and a positive PASRR evaluation screening, but no documentation that a PCSP meeting occurred after the positive evaluation. The MDS Coordinator stated she had been told the resident refused PASRR services, but she did not verify that information with the resident or contact the local authority, and the local authority stated the resident was deemed to have mental illness and qualified for PASRR services. For another resident with paranoid schizophrenia, the record showed a PCSP meeting had recommended habilitation coordination and independent living skills services. The facility record did not contain documentation of habilitation coordination or independent living skills training notes. The habilitation coordinator and skill trainer stated they visited the resident at the facility, but neither left documentation there, and the MDS Coordinator stated she was responsible for ensuring the visits were conducted and did not coordinate with them after their visits. The DON and Administrator also stated they did not know what services the resident was receiving until surveyor intervention and that there was no system in place to monitor oversight of needs. A third resident with bipolar disorder, PTSD, acute respiratory failure, and muscle weakness had a PASRR Level 2 assessment and a Comprehensive Service Plan that listed medication training, routine case management, and counseling services, with Medicaid eligibility later shown to have begun on 04/01/25. The record did not show that the local authority was notified of the Medicaid eligibility to start PASRR services. Staff interviews reflected uncertainty about who was responsible for PASRR follow-up, and the DON and Administrator stated the resident was at risk of not receiving requested services. For a fourth resident with diagnoses including major depressive disorder, anxiety disorder, hallucinations, and PTSD, the PASRR screening did not indicate PTSD even though the medical record and trauma-informed care form documented PTSD, trauma history, and triggers such as loud noises, specific smells, restraints, and large crowds. The baseline care plan and orders did not reflect mental health needs or trauma-related monitoring, and the MDS Nurse stated she made a mistake by not doing a correct screening.
Catheter securement and indication deficiencies
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #8, a cognitively intact male with diagnoses including bladder neck obstruction and urinary retention. His care plan stated that his indwelling catheter should be secured with a leg strap at all times, and the physician order summary included an order to check foley leg strap placement each shift. During observation, he was seen sitting in his wheelchair with the catheter tubing not secured, and he told the surveyor it had not been secured for a few weeks. A LVN stated the catheter did not have to be secured because it was easier for the resident to move the bag from his wheelchair, while another LVN stated the catheter should always be secured and that it was important to prevent trauma to the perineal area. The facility also failed to ensure Resident #23’s catheter was secured. Resident #23 was a cognitively intact male with diagnoses including paraplegia, heart failure, urinary retention, and major depressive disorder, and his MDS indicated he required total assistance for several activities of daily living. His care plan identified a suprapubic catheter and his orders included checking the foley leg strap placement every shift. During observation, he was seen with tape on his leg that was not attached to the catheter tubing, and he stated the facility did not have supplies. On a later observation, he again had tape on his leg but not attached to the catheter tubing and said he needed the actual securement device because the tubing moving around was making his stoma sore. A LVN later applied the securement device and stated the resident was supposed to have his catheter secured at all times. The facility also failed to have an appropriate diagnosis or indication for Resident #70’s indwelling catheter. Resident #70 was a female admitted with diagnoses including COPD, diabetes, and hypertension, and her baseline care plan listed an indwelling catheter without interventions. Her physician order dated 03/27/26 ordered an 18 French indwelling catheter with a 30 ml bulb to be changed as needed, but the record did not show an indication or diagnosis for the catheter. During interview, the resident said she did not know why she had the catheter. The RN caring for her stated he did not know why she had the catheter and did not see a diagnosis for it in the orders, and the DON stated staff were responsible for ensuring they received a diagnosis for residents admitted with an indwelling catheter and that the catheter should not be in place without appropriate rationale and/or diagnosis for use.
Unsecured medications and unlabeled insulin pen found during survey
Penalty
Summary
Drugs and biologicals were not consistently stored in a locked, secure manner in the facility. During an observation on the hall 100 medication room refrigerator, Resident #54 had one open bottle of Lorazepam and two unopened bottles of Morphine Sulfate in the refrigerator door, and Resident #39 had one open bottle of Morphine Sulfate in the same refrigerator door. The DON observed the medications and stated she was not aware they were in the refrigerator door and believed they were double locked because they were in the medication room and refrigerator door. She also stated the risk could be drug diversion. Resident #54 was a male with diagnoses including dementia, depression, stroke, and high blood sugar, and his MDS showed severe cognitive impairment with a BIMS score of 00. He was on hospice and had orders for Lorazepam oral concentrate as needed for anxiety/agitation and Morphine Sulfate oral solution as needed for shortness of breath or pain. Resident #39 was a male with diagnoses including dementia, depression, and stroke, and his MDS showed moderate cognitive impairment with a BIMS score of 09. He had chronic pain and an order for Morphine Sulfate oral solution as needed for shortness of breath or pain. Neither resident’s narcotic sheet indicated missing medication, but the medications were found unsecured in the refrigerator door. On the 300-hall medication cart, an insulin pen for Resident #5 was found in the top drawer opened with no date written on it. Resident #5 was a male with diabetes, dementia, depression, and muscle weakness, and his care plan and physician order showed he received insulin glargine at bedtime. RN G stated the insulin pen should have been dated when opened, and LVN K stated the date of opening was unknown even though the pen was believed to be within the 28-day use period. In addition, wound cleanser was found on Resident #16’s nightstand in her room, and Resident #23 had triad hydrophilic wound paste in his bedside drawer along with triple antibiotic ointment and hydrocortisone cream on his bedside table in an open storage container. Resident #16 had an order for wound cleanser for a left shin wound, and staff stated the cleanser should not be in a resident’s room. Resident #23 had an order for triad to the sacrum, but the order summary did not include hydrocortisone cream or triple antibiotic ointment. Staff stated Resident #23 should not have medications in his room, and the DON stated there should have been no medications in the room and that the facility should have had a self-administration assessment if he was to keep medications there.
Food Not Served at Palatable, Attractive, and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents during lunch service. In a Resident Council Meeting on 4/1/2026 at 10:00 am, all 8 residents said the food was bland and served warm. During surveyor observations, the last food temperature was checked on the warming table at 12:48 pm, trays were prepared, and service began at 12:52 pm. A test tray was prepared at 12:59 pm, and at 1:08 pm the tray cart with the test tray left the kitchen preparation area, was checked by nurses, and went to hall 300. The test tray arrived to the conference room at 1:14 pm. During a test tray interview at 1:15 pm, the Dietary Manager stated the fried pork chops with white gravy could be warmer, the candied yams were okay but could use more butter and sugar because they were kind of bland, the cauliflower with cheese sauce was nice and warm with okay flavor, and the lemon pudding could be cooler. The food on the plate was observed to be unattractive. The Dietary Manager later stated he was responsible for ensuring food was palatable and hot when residents received their meal trays and said he had received complaints about the food in the last three months. The Administrator stated he expected food to appear appetizing, taste good, and be delivered hot, and said the food should look appetizing because a person eats with his or her eyes first. Record review showed the regular meat was 183 degrees Fahrenheit, white gravy 170 degrees, candied yams 183 degrees, cauliflower with cheese sauce 145 degrees, cornbread 114 degrees, and lemon pudding 60 degrees at the time of serving.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food safety requirements. During the initial kitchen tour, the dietary manager was not wearing a hair net or beard cover, another staff member was not wearing a beard cover, and a dietary aide was not wearing a hair net. The microwave had a red sticky substance splattered on the walls and top, two unopened bags of shredded carrots in the refrigerator were past their expiration date, the deep fryer grease was dark brown with burnt food particles floating on top, and the inside of the juice nozzle was covered in a black film. During interviews, the dietary manager stated his hair and beard were less than one inch long and he did not need a hair net, and he acknowledged responsibility for ensuring staff wore hair restraints and that expired items were removed from the refrigerator. He also stated the microwave was to be cleaned as needed, the fryer grease had been changed four or five days earlier and needed to be cleaned out, and the juice nozzle was dirty and needed cleaning. Staff interviewed stated they did not know or forgot about the hair restraint requirements and acknowledged that dirty equipment and expired food could make people sick. The administrator stated he expected proper hair restraints, regular cleaning of kitchen equipment, fresh fryer grease free of floating food particles, and no out-of-date or expired food in the kitchen.
Failure to Maintain Privacy Bag Over Indwelling Catheter
Penalty
Summary
The facility failed to ensure Resident #70 was treated with respect and dignity by not maintaining a privacy bag over her indwelling catheter. Resident #70 was a female admitted with diagnoses including COPD, diabetes, and high blood pressure. Her baseline care plan identified that she had an indwelling catheter, and physician orders dated 03/27/26 included an indwelling catheter and a privacy bag or covering over the urine collection bag for dignity every shift. The resident’s medication administration records showed the catheter remained in place throughout the month, and the privacy bag order was signed every shift as if the bag was intact. During observation on 03/31/26, Resident #70 was lying in bed with her indwelling catheter hanging with no privacy bag, and she said she did not realize the catheter bag was not covered. A later observation on 04/01/26 again showed the catheter exposed without a cover. RN G said he did not know why the privacy bag was not on the catheter and stated he had put a new privacy bag on it on 04/01/26, adding that staff sometimes forget to reapply the privacy bag when moving residents and that the lack of a privacy bag could be a dignity issue. The DON stated all residents with indwelling catheters should have a privacy bag for dignity issues and that nursing staff were responsible for ensuring it was in place. The Administrator stated anyone with a catheter should have an order and privacy bag, and that the nurse was responsible for ensuring the catheter was secured and the resident had a privacy bag.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that Resident #9 was informed of and participated in his treatment when it did not obtain informed consent for the antipsychotic Zyprexa (Olanzapine) before administration began on 1/25/26. Resident #9 was a male admitted with diagnoses of major depressive disorder and hallucinations. His admission MDS reflected that he made himself understood, understood others, and had a BIMS score of 15, indicating intact cognition. The record showed Olanzapine 5 mg by mouth twice daily was ordered for hallucinations and was administered at the 8:00 am and 8:00 pm medication passes daily since 1/25/26. Record review of the EMR on 4/2/26 revealed no signed consent form for the medication at that time. A pharmaceutical review dated 1/31/26 recommended ensuring a signed consent form was scanned into PCC for Olanzapine on Texas form 3713. The EMR later contained Texas Health and Human Services Form 3713, Consent for Antipsychotic or Neuroleptic Medication Treatment, signed by Resident #9 and the medical director and dated 4/3/26 for Olanzapine. Interviews with the Executive Director, DON, and Administrator confirmed that consents should be obtained and documented before administration of medications requiring consent, and that the ADON, DON, and nursing staff were responsible for ensuring those consents were completed and uploaded into the chart.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #64 had a call button within reach. Resident #64 was a [AGE]-year-old female admitted with diagnoses including dementia, depression, and muscle weakness. Her quarterly MDS reflected that she understood others and made herself understood, had a BIMS score of 13 indicating intact cognition, and required total assistance with toileting, personal hygiene, transfer, and bathing, along with maximal assistance with eating. Her care plan identified her as a fall risk and directed staff to anticipate and meet her needs, keep the call light within reach, and respond promptly to requests for assistance. During observations, Resident #64 was found in bed with her call light on the bedside table and not within reach, and she stated she usually had to holler out if she needed assistance. A CNA verified the call light was not in reach and said the cord was not long enough, placing it on the bed instead. The charge nurse later confirmed the resident could not reach the pull cord because it was too short and stated the resident could benefit from a push pad call light system. The DON and Administrator both stated call lights should be within reach and that residents should have a means to call staff for assistance; the facility policy also stated each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
MDS Incorrectly Coded Resident’s Primary Language
Penalty
Summary
The facility failed to ensure Resident #48’s quarterly MDS accurately reflected her primary language. The resident’s face sheet identified her as a female admitted with diagnoses including progressive loss of cognitive function and brain tissue associated with aging. However, the quarterly MDS dated 01/10/26 coded her preferred language as English and indicated she did not need or want an interpreter to communicate with a doctor or health care staff, while also documenting that she made herself understood and understood others. The same assessment reflected a BIMS score of 4, indicating severe cognitive impairment. Record review showed the resident’s comprehensive care plan, revised on 11/05/24, identified a communication problem related to a language barrier, noting she was Spanish speaking, did not speak English well, and got embarrassed in group settings. An undated facility form also reflected that she spoke in a non-dominant language. During interviews, the MDS Coordinator stated the resident’s primary language should have been coded as Spanish and that a translator was needed to communicate with staff. The Regional MDS Coordinator, DON, and Administrator also stated the assessment should have reflected Spanish as the primary language and that the MDS should be coded accurately to reflect the resident’s situation.
CNA Applied Wound Paste Outside Scope of Practice
Penalty
Summary
The facility failed to ensure that services outlined in Resident #23’s comprehensive care plan were provided by qualified persons. Resident #23 was a re-admitted male with diagnoses including major depressive disorder, paraplegia, heart failure, urinary retention, and hypertension. His quarterly MDS indicated he was cognitively intact with a BIMS score of 15 and required total assistance for transfers, bed mobility, and bathing. His care plan included sacral region moisture associated skin damage with an order to cleanse with wound cleanser, apply Triad paste, and leave the area open to air, and the order summary listed Triad to the sacrum every evening shift. During observation, CNA B provided catheter care and then applied Triad hydrophilic wound dressing paste to Resident #23’s bilateral buttocks after retrieving it from the resident’s nightstand drawer. CNA B stated he used the Triad daily and believed there was an order for it, along with another butt paste order, and said the nurse usually handed CNAs the barrier cream in a clear medication cup. Later interviews showed LVN A and LVN K stated CNAs should not apply Triad because it was outside their scope of practice, and the nurse should apply it to assess the area and monitor progress. CNA B later acknowledged he was not a nurse and should not have applied the Triad. The ADON, DON, and Administrator all stated CNAs should not administer prescription or chemical-grade medications, and the facility policy stated only individuals licensed or legally authorized may prepare, administer, and document medications.
Failure to Provide Effective Communication Assistance
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that residents’ abilities in activities of daily living did not diminish based on their comprehensive assessments and consistent with their needs and choices for 2 of 2 residents reviewed. The deficiency centered on communication assistance, as the facility did not ensure effective communication for a resident with severe cognitive impairment and Spanish as the primary language, and for another resident who was blind and also had Spanish as the primary language. Resident #48’s record showed diagnoses including progressive loss of cognitive function and brain tissue associated with aging. Her quarterly MDS reflected a BIMS score of 4, severe cognitive impairment, and listed English as her preferred language with no interpreter needed, while the care plan identified a communication problem related to a language barrier, noting she was Spanish speaking and did not speak English well. During observation, she was eating lunch and told the surveyor she spoke little English, and no communication device was observed in her room. Family and multiple staff interviews described that she primarily spoke Spanish, that staff often relied on hand gestures, writing, or phone translation, and that some staff were unaware of the tablet translation app. The DON stated she expected the MDS to identify Spanish as the primary language and acknowledged she had never had a full conversation with the resident. Resident #46’s record showed diagnoses including blindness, stroke, and high blood pressure. Her quarterly MDS indicated she was cognitively intact, required total assistance with multiple ADLs, and had Spanish as her primary language. Her care plan identified risk related to blindness, language barrier, and difficulty interpreting staff actions during meal assistance, with an intervention to use certified interpreter services or facility-approved language assistance. During observation, she responded in Spanish when spoken to in English, and no communication device was observed in her room. Staff interviews stated she spoke very little English, that communication was often done using phone translation or an app, and that no communication board or tool had been provided that they were aware of. The DON and Administrator stated the facility had a tablet app and communication board available, but staff interviews and the record review showed inconsistent awareness and use of those tools.
Failure to Apply Ordered Wrist Roll for Contracture Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve range of motion for Resident #14, who had cerebral palsy, traumatic brain injury, contractures, and functional limitation in range of motion on both the upper and lower extremities. The resident’s care plan, revised 02/13/25, directed staff to have the resident wear a left wrist roll daily or as tolerated for contracture prevention and management, and the physician order summary dated 04/03/26 reflected an active order for the same intervention beginning 12/23/25. During observations on 03/31/26, 04/01/26, and 04/02/26, the resident was seen sitting in a Broda chair or lying in bed without the left wrist roll in place. Each time, the wrist roll was observed lying on the resident’s dresser instead of being applied to the left wrist. The resident was non-interviewable due to cognitive loss, and the quarterly MDS reflected that he rarely or never understood others and rarely or never made himself understood, with long-term and short-term memory problems noted. Staff interviews showed the CNAs and LVNs were responsible for applying the wrist roll, but CNA C stated she had seen it on the dresser and was never told what hand it should go in. LVN A stated the resident should have the wrist roll in his left hand and that staff were responsible for ensuring it was applied, though he could not recall exactly when he last placed it there. The DOR and DON both stated the wrist roll should be in the resident’s left hand during daily functional tasks while sitting or lying, and the DON stated she had noticed in the past that it was not applied. The Administrator stated he did not know the resident was supposed to have the left wrist roll daily.
Missing oxygen orders and dirty oxygen equipment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who were receiving oxygen. Resident #70, a female with COPD, diabetes, and hypertension, had a baseline care plan that indicated she used oxygen, but her physician orders did not include an oxygen order. During observation, she was in bed alert with oxygen set at 5 liters per nasal cannula, and she stated she wore oxygen because it helped her breathe better. RN G later reviewed her orders and confirmed that the oxygen order was missing, stating the resident required oxygen and that the correct oxygen rate should be known by staff. Resident #47, a female with acute and chronic respiratory failure, diabetes, hypertension, dementia, and congestive heart failure, was observed lying in bed with oxygen set at 2 liters per minute. Her oxygen concentrator filter was observed on multiple occasions to be covered in gray matter. Her quarterly MDS did not indicate oxygen use, her comprehensive care plan did not include oxygen, and her order summary did not show an oxygen order. The ADON stated there should have been a schedule for cleaning oxygen concentrator filters and changing nasal cannulas, and said the filter appeared dirty and should have been cleaned and the tubing changed weekly. The DON stated nurses were responsible for writing physician orders when received and said residents who wore oxygen should have orders written with the oxygen rate, diagnosis, and a sign on the door. She also stated the nasal cannula should be changed weekly and the oxygen concentrator filter should be cleaned. The Administrator stated nurses should have been changing and cleaning the oxygen concentrator filters and monitoring cleanliness every Sunday, and said both residents should have had oxygen orders. The facility policy reviewed by surveyors stated there should be a physician order for oxygen administration and that oxygen equipment should be kept free of grease and oil.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not ensured for Resident #9, a male admitted with chronic kidney disease stage 5, major depressive disorder, anxiety disorder, hallucinations, and post-traumatic stress disorder (PTSD). The admission MDS reflected an active PTSD diagnosis and a BIMS score of 15, indicating intact cognition. However, the pre-admission PASRR dated 1/23/26 indicated no diagnosis or history of PTSD or other mental illness, while the Social History Form-Trauma Informed Care dated 1/29/26 documented a history of trauma, a PTSD diagnosis, and triggers including loud noises, specific smells, restraints, and large crowds. The form also noted that removing stimuli and medications prescribed for the trauma-related diagnosis helped alleviate the triggers. Despite this information, the resident’s baseline care plan dated 1/31/26 listed no mental health needs, no behavioral concerns, and no interventions for PTSD. The resident’s orders dated 4/3/26 also did not include monitoring for traumatic stress behaviors or triggers. During interviews, the DON stated the Social Worker was responsible for ensuring PTSD triggers were on the chart and that trauma-informed care was important to avoid triggers. The Administrator stated all residents with PTSD were expected to have trauma-informed care and that the Social Worker, ADON, and DON were responsible for knowing the diagnosis and proceeding accordingly. The Social Worker stated the trauma assessment was part of the initial admission assessment and acknowledged Resident #9 did trigger for trauma-informed care.
Controlled medication receipt and narcotic count failures
Penalty
Summary
The facility failed to provide pharmaceutical services for controlled medications awaiting disposition because it did not keep a record of receipt for those medications. During observation, controlled medications were found in the locked cabinet awaiting disposal, including Tramadol 50 mg tablets, Lorazepam 0.5 mg tablets, and Morphine 20 mg/ml. The DON stated she was responsible for discontinued medications, that she checked the narcotic count with the nurse, logged the medication on the destruction log kept in the cabinet, and then placed the medication in the locked cabinet. She also stated she could see where she had started to log one of the medications but it was not completed. The facility’s medication destruction binder showed the last medication destruction was completed on 02/20/26. The facility also failed to ensure narcotic medications stored in the hall 100 medication room refrigerator were counted. During observation, an open bottle of Lorazepam and Morphine and two unopened bottles of Morphine Sulfate were seen in the refrigerator door. An LVN stated she was the charge nurse for the shift and did not count the medications in the refrigerator, and said she did not know those medications were there. Another LVN stated he was the charge nurse on hall 100 for two shifts and did not count the resident medications in the refrigerator on either day, although he knew they were inside the refrigerator on the shelf inside the door. A third LVN said she did not recall counting any medications in the refrigerator and stated nurses were supposed to count all narcotics each shift. The DON stated narcotic medications should always be stored under double lock, including medications in the refrigerator, and that nurses should count narcotics each shift. The Administrator stated the nurses should be counting narcotics every shift and that the DON was responsible for monitoring and overseeing nurses by rounding. The facility policy stated controlled substance inventory is monitored and reconciled to identify loss or potential diversion, and that waste or disposal of controlled medication is done in the presence of the nurse and a witness who signs the disposition sheet.
Missed Ordered Lab Tests for Two Residents
Penalty
Summary
The facility failed to ensure laboratory services were obtained for 2 of 24 residents reviewed for lab services. Resident #14 had a seizure disorder related to shaken infant syndrome, was rarely or never able to understand others or make himself understood, and had long- and short-term memory problems noted on the quarterly MDS. His care plan directed staff to give medications as ordered, monitor lab results, and report subtherapeutic or toxic results to the MD. The physician order summary showed an active order for a Tegretol level every four months, starting on the last day of the month, with a start date of 10/31/23, but the electronic record showed the last Tegretol level was drawn on 10/31/25. Resident #18 was admitted with a diagnosis of vitamin D deficiency. Her quarterly MDS reflected intact cognition with a BIMS score of 15. Her care plan identified a nutritional problem or potential nutritional problem and risk for malnutrition related to malnutrition, vitamin deficiency, and cachexia, with interventions to administer medications as ordered and monitor/document side effects and effectiveness. The physician order summary showed an active order for vitamin D with a start date of 02/25/26, but the electronic health record did not reflect a vitamin D level drawn as ordered. During interview, the ADON stated she was responsible for monitoring and reviewing labs in PCC each morning and had seen the lab orders for Resident #14’s Tegretol level and Resident #18’s vitamin D level, but clicked the box showing them as completed. She stated she should have contacted the lab to complete the orders and placed the requisition in the lab book, and that she thought the labs had already been drawn. The ADON also stated she had not been trained on how to properly review unreviewed lab results until the day before the interview. The Medical Director, DON, and Administrator each stated labs were expected to be drawn as ordered, and the DON stated the lab company comes in daily to draw labs.
Failure to Honor Resident Food Preference for Double Vegetables
Penalty
Summary
The facility failed to ensure that Resident #18 received food that accommodated her stated preference for double vegetables. Resident #18 was a female resident admitted with diagnoses including vitamin D deficiency and unspecified severe protein-calorie malnutrition. Her quarterly MDS reflected that she understood others, could make herself understood, and had a BIMS score of 15, indicating intact cognition. Her care plan identified a nutritional problem or potential nutritional problem related to malnutrition, vitamin deficiency, and cachexia, and her physician order summary included an active order to add double vegetables to meals per patient request. During the lunch meal observation, Resident #18 received one serving of cauliflower with cheese sauce instead of double vegetables, even though the meal ticket reflected extra vegetables. CNA C and the Executive Director reviewed the ticket and agreed she did not receive double vegetables. LVN P stated she was responsible for ensuring the resident received double vegetables but was unaware she needed them and had not read the ticket completely. Another staff member stated she overlooked the ticket while preparing the tray. The Dietary Manager stated he knew the resident wanted double vegetables, assumed it was related to her health, and identified the nurse as responsible for ensuring the correct portion was served. The DON and Administrator both stated they expected food preferences to be followed and that staff were responsible for checking trays against tickets.
Failure to Provide Ordered Double Protein Portion
Penalty
Summary
The facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 24 residents reviewed for therapeutic diets. Resident #18, a [AGE]-year-old female admitted with diagnoses including vitamin D deficiency and unspecified severe protein-calorie malnutrition, had a BIMS score of 15 and was documented as cognitively intact. Her care plan identified a nutritional problem and risk for malnutrition related to malnutrition, vitamin deficiency, and cachexia, and included an intervention to provide and serve the diet as ordered. Her physician order summary reflected an active order for double protein with a start date of 06/22/25. During lunch meal observation on 04/01/26, Resident #18 received a single serving of the entree, a pork chop, even though the meal ticket reflected double protein portion. After review of the ticket with CNA C and the Executive Director, both agreed she did not receive two servings of pork chops. LVN P stated she was responsible for ensuring the resident received double protein with lunch, but was unaware she needed two servings of the entree and said she should have read the complete ticket. The Dietary Manager stated the dietary staff member was responsible for ensuring the resident received two pork chops, and the DON stated the nurse should check trays prior to serving residents. The Administrator stated the cooks were the first line of defense and the nurses were the second line of defense for ensuring residents received the correct dietary orders.
Hospice documentation and medication orders were not kept current or aligned
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate staff participation in the hospice care planning process for a resident receiving hospice services. Resident #9 was a male admitted to the facility with diagnoses including chronic kidney disease stage 5 and heart failure, and his MDS reflected that he was cognitively intact with a BIMS score of 15 and had been admitted to hospice as a resident within the last 14 days. Record review showed he had been evaluated and admitted to hospice, but the facility did not have his most current Hospice Plan of Care/Interdisciplinary Group Reports, Medication Report, or Physician Orders in the current clinical record. Review of the hospice binder showed hospice documentation dated 3/4/26 through 3/18/26, but the hospice medication list did not match the facility's physician orders. The hospice record listed acetaminophen 650 mg rectal suppository every four hours as needed for pain/fever and bisacodyl 10 mg rectal suppository daily as needed for constipation/bowel obstruction, while the facility order summary listed acetaminophen oral packet 500 mg by mouth every six hours as needed for pain and no order for bisacodyl. The hospice Patient Care Manager stated hospice case managers were responsible for keeping the binders updated and communicating changes to the facility, while the DON stated she did not know who was responsible for keeping the hospice binders current and said there was no one currently monitoring ongoing orders. The Administrator later stated the ADON and DON were responsible for monitoring the hospice binders and ensuring they stayed current.
Dirty Linen Not Discarded Properly During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when LVN O did not discard dirty linen properly during wound care for a resident with venous and arterial ulcers. Resident #18 was a female admitted with diagnoses including non-pressure chronic ulcers of the lower leg and peripheral vascular disease. Her quarterly MDS reflected intact cognition with a BIMS score of 15, and her care plan addressed monitoring the right lower extremity venous ulcer for signs and symptoms of infection. Her physician’s order required soaking the legs with warm towels, washing with soap and water, patting dry, applying clobetasol cream and xerofoam, and wrapping with kerlix three times per week. During observation, LVN O performed hand hygiene, applied gloves, removed wet towels from the resident’s leg, and placed them on the resident’s dresser; skin shedding was observed on both towels. LVN O then completed the wound care. In interview, LVN O stated she should have had a plastic bag for the dirty linen before starting the wound care and said she placed the towels on the dresser because she did not have one with her. The ADON, who stated she was the Infection Control Preventionist, and the DON both stated the wet towels should have been placed in a plastic bag instead of on the dresser, and the Administrator stated wet towels were expected to be placed in a plastic bag for disposal.
Unattended and Unsecured Medications on 200 Hall Medication Carts
Penalty
Summary
The deficiency involves failures to properly secure and store medications on two medication carts on the 200 hall. During an observation, a medication aide (MA A) was seen administering medications and left a medication card containing gabapentin 300 mg capsules on top of the 200-hall medication aide cart in a hallway where residents were present. MA A then entered a resident's room to administer medications, leaving the gabapentin card out of her view and unattended. MA A acknowledged that medications should not be left on top of the cart unattended, stated she should have returned the gabapentin to the inside of the cart before going into the room, and recognized that unattended medications could be picked up by residents or staff. In a separate observation, an LVN (LVN B) left an unlocked and unattended nurse medication cart on the 200 hall with a vial of insulin lispro 100 units/mL on top of the cart in front of a resident's room, while staff and residents were present in the area. LVN B exited the resident's room and confirmed it was her cart, stating she had forgotten to put the insulin back inside the cart and lock it before entering the room. She acknowledged that people could pick up medications left on top of the cart and could take medications from inside the cart when it was left unlocked and unattended. The DON stated that medications should not be left on top of medication carts, that carts should be locked whenever staff walk away or turn their backs, and that unattended medications and unlocked carts could result in residents or employees taking medications or residents ingesting them with adverse effects. The Administrator stated he expected medication carts to be locked when not under staff supervision and medications not to be left on top of carts, and that the DON was responsible for monitoring staff compliance. Facility policy on Storage of Medications required all drugs and biologicals to be stored in locked compartments and specified that unlocked medication carts are not to be left unattended.
Medication Administration and Discontinued Drug Storage Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. For a male resident with chronic systolic congestive heart failure and generalized anxiety disorder, the physician had ordered buspirone 5 mg to be given three times daily starting in mid-January 2025. His MDS showed intact cognition (BIMS 15) and documented use of antianxiety and antidepressant medications, and his care plan directed that buspirone be administered as ordered. The MAR from October 2025 through March 2026 showed the buspirone as administered three times daily, except for one documented absence from the facility. However, during a medication pass observation, the buspirone card in use had 42 tablets remaining from a card dispensed in late November 2025, and the medication aide stated there was no overstock for this resident on the cart or in storage. On the following day, surveyors observed that the same medication aide’s cart actually contained three additional overstock cards of buspirone 5 mg for this resident, dispensed in July 2025, October 2025, and January 2026, with substantial tablet counts remaining. In an interview, the resident reported that he sometimes received his midday dose of buspirone and sometimes did not, and that he had reported this to the DON, although he could not recall when. He stated that when he remembered, he would go ask for the medication and that the medication aide in question was the only one not administering his buspirone. The DON acknowledged that the resident had reported not receiving his noon dose from this aide, that she had questioned the aide and reviewed the medication cards, and that she had provided verbal education, but there was no documentation of this. A second deficiency involved a female resident with chronic respiratory failure with hypoxia, bipolar disorder, and depression, whose MDS also showed intact cognition (BIMS 15) and receipt of antidepressant medications. Her care plan addressed depression with administration of medications as ordered. Physician orders showed an active order for sertraline 50 mg once daily and a discontinued order for sertraline 100 mg in the morning, which had been stopped in late January 2026. Despite this discontinuation, surveyors observed both sertraline 100 mg and 50 mg on the medication cart. The medication aide stated she did not know why the discontinued 100 mg dose remained on the cart and acknowledged that discontinued medications should be removed. The DON reported that she relied on weekly cart checks and had not noticed the discontinued sertraline remaining on the cart, while an LVN and another medication aide gave conflicting accounts about whether the discontinuation had been communicated, demonstrating a breakdown in the process for removing discontinued medications from active stock.
Failure to Enforce Droplet Precautions and Proper PPE Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident on droplet precautions. The resident was an adult female with chronic respiratory failure with hypoxia, bipolar disorder, and tracheostomy status, and had a care plan initiated for pneumonia. Physician orders dated 03/05/2026 directed that the resident be placed on droplet isolation precautions related to flu/pneumonia starting 03/04/2026. A droplet precaution sign was posted beside the resident’s doorframe, and a cart with face shields, face masks, gowns, gloves, and shoe covers was placed outside the room. However, the resident’s care plan did not address the use of droplet precautions. On 03/04/2026 at 10:31 AM, a CNA was observed inside the resident’s room without any PPE, despite the posted droplet precaution sign and available PPE cart. After noticing the surveyor, the CNA exited the room, donned a face mask, face shield, and gown, and re-entered the room. When leaving the room, the CNA removed PPE in the hallway instead of before exiting the resident’s room. In a subsequent interview, the CNA stated she was not aware the resident required droplet precautions, said she had been in a rush and did not pay attention to the sign, and acknowledged that PPE should be removed before leaving residents’ rooms and that proper PPE use was important for infection control. On 03/04/2026 at 11:13 AM, a medication aide donned a face mask, gown, and gloves, but not a face shield, before entering the resident’s room to administer medications, and then removed PPE in the hallway. The medication aide stated she did not need a face shield because she was not in the room for a long time and believed removing PPE in the hallway was appropriate. On 03/05/2026 at 8:21 AM, the same medication aide again wore a face mask, gown, and gloves to enter the room, exited into the hallway still wearing the gown and mask, removed only her gloves, performed hand hygiene, donned new gloves, prepared medications in the hallway, and administered them to the resident without removing the gown and mask before exiting the room. The DON stated that droplet precautions for this resident required staff to don a face mask, face shield, gown, and gloves prior to entering the room and to remove PPE before exiting, and the Administrator stated he expected staff to follow facility protocol. The facility’s written Infection Prevention and Control Program referenced educating staff and ensuring adherence to proper techniques but did not specifically address PPE requirements for droplet precautions, and a droplet-specific policy was requested but not provided.
Dialysis Communication and Assessment Deficiency
Penalty
Summary
The facility failed to ensure dialysis services were provided consistently with professional standards of practice for one resident who required dialysis. The resident was a cognitively intact male with end stage renal disease who was dependent on staff for toileting, bathing, dressing, and required moderate assistance for bed mobility. His care plan identified dialysis on Tuesday, Thursday, and Friday with monitoring and documentation for signs and symptoms of renal insufficiency, and his order summary later reflected in-house dialysis three days a week on Tuesday, Thursday, and Saturday. Record review showed no documented before-and-after assessments and no ongoing communication with the dialysis service for the resident on multiple dialysis treatment dates, even though he attended dialysis on those dates. During interviews, the RN, DON, and Administrator stated that charge nurses were responsible for completing dialysis communication forms before and after treatments and for ensuring the forms were completed and uploaded to the resident’s chart. The facility policy on Dialysis Protocols stated that dialysis days were to be established and the IDT informed, and that dialysis communication regarding the plan of care was to be implemented.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors determined the medication error rate was 13.33%, based on 4 errors out of 30 opportunities, involving 2 residents and 1 staff member reviewed for medication administration. One resident had diagnoses including schizophrenia and major depressive disorder, a BIMS score of 15 indicating intact cognition, and was dependent on staff for toileting, dressing, and personal hygiene. Her orders included escitalopram 10 mg daily, aripiprazole oral solution 1 mg daily, and amantadine syrup 50 mg/5 ml, 10 ml daily. The MAR showed these medications were documented as administered, but during observation the medications were not given at that time, and the medication aide stated they had been administered earlier because the resident requested them. A second resident had an order for carvedilol to be given with meals, but the medication aide did not administer it with meals as ordered. During interview, the aide stated she had given the first resident's medications earlier than the observed administration. The survey also noted that when the first resident was interviewed, she said the observed medication pass was the only time she received medications and that she did not know the names of all her medications. The report also documented multiple full bottles of amantadine and aripiprazole and a medication card for escitalopram with tablets remaining, consistent with the medication administration concerns identified during the survey.
Medication Labels Did Not Match Orders and Medications Were Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles and matched the residents’ current physician orders. Resident #50, a female with schizophrenia and major depressive disorder and a BIMS score of 15, had orders for famotidine, aripiprazole oral solution, and amantadine syrup. During medication administration observation, her famotidine label instructed administration via gastrostomy tube twice daily, while the resident was receiving the medication by mouth and there was no label indicating the order had changed. The labels for aripiprazole and amantadine also instructed administration via g-tube, although staff stated the resident received all medications by mouth and her g-tube had been removed. Resident #52, a male with a history of cerebral infarction, hypertension, and dementia with a BIMS score of 00, had an order for tamsulosin 0.4 mg by mouth one time a day. During observation, the medication label instructed administration at bedtime, while the resident was receiving the medication in the morning. Staff stated the order had changed months earlier, but the medication label had not been updated to match the current order. The DON and Administrator both stated that medication labels were expected to match the order and that a change-of-order label should be placed on the medication card when orders changed. The facility also failed to ensure medications and biologicals were stored in locked compartments and not left accessible in resident rooms. Resident #7, a cognitively intact male with end stage renal disease, chronic systolic heart failure, respiratory failure, bipolar disorder, and a pressure ulcer, had wound care orders for wound cleanser, Dakins-moistened gauze, and superabsorbent dressing. Observations showed two bottles of wound cleanser, Medi honey, and one or two Fleet enemas on his dresser on multiple occasions. RN G stated these items should not have been in the room and that she removed such items when providing care. The DON stated prescription medications should not be in residents’ rooms and should be locked in medication carts or medication rooms, and the Administrator stated anything for medical use should be put away where only authorized staff had access.
Dietary Staff Worked Without Current Food Handler Certificates
Penalty
Summary
The facility failed to employ sufficient staff with appropriate competencies and skills to carry out the functions of the food and nutrition service for 3 of 8 dietary staff reviewed: Cook N, [NAME] O, and Kitchen Aide P. Record review showed that Cook N’s Texas Food Handler Certificate was issued after state surveyor intervention and there was no other food handler certificate on file. [NAME] O’s employee file showed a Texas Food Handler Certificate issued after state surveyor intervention, and the certificate previously on file had expired. Kitchen Aide P’s employee file also showed a Texas Food Handler Certificate issued after state surveyor intervention, and the certificate previously on file had expired. During interview, the Dietary Manager said the food handler certificates should have been completed before employees started in the kitchen, but he had worked at the hospital prior to starting at the facility in October and was unaware he was responsible for getting the certificates completed. He said he thought the staff had already completed the certificates when he started in his position. The Dietary Manager stated the lack of current food handler certificates placed a risk because staff might not know procedures, especially handwashing, and could create a risk for cross contamination and infection. The DON said she expected kitchen staff to follow policies and the dietician to notify her of any issues. The Administrator said the facility did not have a policy regarding food handler certificates, and stated his expectation was that all kitchen staff had the food handler certificate before it expired and before beginning to work.
Food Served Lukewarm and Unappetizing at Lunch
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for one kitchen meal, lunch, and for three residents reviewed for food and nutrition services. During interviews, Resident #35 said the food was not very good, tasted bad, and about half the time it was cold. Resident #4 said the food did not taste good and was not warm enough. Resident #40 said she wished the food tasted better and described it as bland. During observation on 12/02/2025, the last hall trays, including the sample tray, left the kitchen and were delivered to the surveyors with the Dietary Manager present. The sample tray contained rotisserie chicken, fried okra, baked beans, cornbread, and pudding. The Dietary Manager said the tray was lukewarm and that if he had received it on the halls, he would not want to eat it. He stated the kitchen was responsible for preparing the food and the aides were responsible for getting the food to residents in a timely manner so it would be hot, and that it took too long to get the trays out. The surveyors and Dietary Manager agreed the chicken, okra, and baked beans were warm but could have been hotter, and the baked beans were bland; the cornbread was warm and not completely done in the middle with a gooey texture. The DON stated the food should have been delivered in a timely manner and should have been hot when residents received it.
Infection Control Failures During Isolation, Pericare, and Transfer Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. Resident #45, a female with a history of stroke and left-sided hemiplegia, had shingles and was on acyclovir with enhanced barrier precautions noted in the care plan. Her order summary did not specify the type of isolation precaution required, and the sign on her door did not identify contact precautions or the PPE to use. During observations, the door displayed only a generic "Stop Please See Nurse Before Entering" sign, and staff stated they were not told what type of precautions were required. RN H and the DON both stated Resident #45 required contact precautions. Resident #27, a male with neuromuscular bladder dysfunction, quadriplegia, seizures, and muscle weakness, was totally dependent for care and frequently incontinent of bowel and bladder. During observed incontinent care, CNA L and CNA B provided pericare after a bowel movement, but the wiping was performed with back-to-front and front-to-back motions using the same wipe, and bowel material was smeared on the resident's buttocks. CNA B also changed gloves several times during the care without performing hand hygiene each time. CNA B later stated she did not realize she had failed to perform hand hygiene before changing gloves and acknowledged that improper hand hygiene and wiping technique could cause cross-contamination. Resident #7, a cognitively intact male with end stage renal disease, chronic systolic heart failure, respiratory failure, and bipolar disorder, had enhanced barrier precautions related to wounds and dialysis, including use during high-contact care such as transfers. During an observed mechanical lift transfer, CNA M transferred the resident without PPE, and CNA L entered and assisted without PPE as well. The resident had an enhanced barrier precaution sign on the door and PPE was available outside the room. CNA M stated staff should have been using PPE for the transfer because the resident was a dialysis resident, and RN G, the DON, and the Administrator all stated PPE should have been used during the transfer.
Incomplete Care Plans for Medication, Smoking Status, and Tracheostomy Change
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 6 residents reviewed. Resident #2 had diagnoses including anxiety and was cognitively intact with a BIMS score of 15. A physician order dated 08/01/25 started Hydroxyzine HCl 25 mg by mouth twice daily for anxiety, and the medication administration record showed the resident continued to receive it during the review period. However, the comprehensive care plan dated 09/02/25 did not address Hydroxyzine for anxiety. Resident #55 had diagnoses including dementia, traumatic brain injury, and seizures. Her quarterly MDS indicated severe cognitive impairment with a BIMS score of 07, and the comprehensive care plan dated 02/11/25 identified her as a smoker at risk for injury due to smoking preference, with interventions including evaluation of smoking safety abilities, education, notification of the RP, and staff keeping her smoking supplies. The Smoking Screen Assessment dated 03/03/25 indicated she was a safe smoker, but during observation on 12/01/25 she was seen going outside with a cigarette in her mouth, using a lighter from her pocket, and stating she kept her own smoking supplies. The care plan was not updated to reflect the change from supervised smoking to unsupervised smoking. Resident #40 had diagnoses including respiratory failure, tracheostomy status, sleep apnea, and heart failure. Her quarterly MDS indicated she was cognitively intact with a BIMS score of 15 and required tracheostomy care. The comprehensive care plan revised on 07/30/25 addressed a 7.0 ID tracheostomy and included respiratory monitoring and trach emergency procedures, while physician orders dated 09/29/25 directed tracheostomy care every shift and as needed but did not indicate the size. During interview, the MDS Coordinator stated Resident #40's tracheostomy size was 6.0 and the care plan should have been updated to reflect the correct size. The facility policy stated comprehensive person-centered care plans are to be developed and revised when a resident's condition changes and at least quarterly.
Failure to Provide Ongoing Activities for a Low-Functioning Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of Resident #10. Resident #10 was a male with diagnoses including cerebral palsy, unspecified convulsions, and shaken infant syndrome. The quarterly MDS assessment showed Section F, Preferences for Customary Routine and Activities, was not completed because the resident was rarely or never understood and no family interview was completed. Resident #10 was totally dependent for all ADLs, including eating, dressing, toileting, bathing, transfers, and mobility. The care plan identified little or no activity involvement related to physical limitations, with a goal for him to participate in activities of choice 3 times per week, and interventions noted he required assistance or escort to activity functions and enjoyed being read to in his room.
Failure to Apply Ordered Left Wrist Roll for Contracture Management
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received the ordered treatment and services to maintain or improve ROM. Resident #10 was a severely cognitively impaired male with cerebral palsy, muscle contractures, convulsions, and shaken infant syndrome. His MDS indicated functional limitations in ROM to the upper and lower extremities, wheelchair use, total dependence for ADLs, and receipt of OT services. His care plan and physician’s order directed that he wear a left wrist roll daily or as tolerated for contracture prevention and management, and the care plan also referenced a left palm protector and splinting for contracture management. Although the November and December 2025 TAR documented that nursing recorded the left wrist roll as in place twice daily, repeated observations of the resident on multiple occasions from 12/01/2025 through 12/03/2025 found no left wrist roll in place. Staff interviews showed inconsistent awareness of the device and its use. CNAs stated they were not aware of a left wrist roll or had not seen or applied one for the resident, and an LVN stated she was not aware of the device but would apply it when it appeared on the TAR. An RN stated she applied a left-hand roll on 12/02/25 and had not yet applied one on 12/03/25, and said it was important to apply the hand roll to prevent further contractures. The DOR stated nursing staff were responsible for applying the hand roll daily, while OT provided weekly passive ROM during habilitative services. The DON and Administrator stated they expected therapy and nursing to implement splinting or contracture management devices per physician orders, and the facility policy described a contracture management program intended to prevent new contractures and maintain or improve ROM.
Mechanical Lift Transfer Completed Without Required Two-Person Assist
Penalty
Summary
The facility failed to ensure Resident #7’s environment remained free of accident hazards when he was transferred with a mechanical lift without two staff members present throughout the entire transfer. Resident #7 was a [AGE]-year-old male who re-admitted to the facility with diagnoses including end stage renal disease, chronic systolic heart failure, respiratory failure, and bipolar disorder. His quarterly MDS indicated he was cognitively intact with a BIMS score of 15, and he was totally dependent on staff for toileting, bathing, and dressing, with moderate assistance needed for bed mobility. His care plan identified an ADL self-care performance deficit related to limited mobility, limited ROM, and musculoskeletal impairment, with an intervention that he required two staff for transfers. During observation and interview, CNA M was seen transferring Resident #7 alone with the mechanical lift by applying the lift pad and raising him into the air. After Resident #7 was already in the air and moved over to the bed, CNA L entered the room and assisted in completing the transfer by placing Resident #7 on the bed. CNA M stated CNA L had been in the room a couple of minutes earlier, while CNA L stated he was not in the room before being told by the nurse to go assist. Resident #7 said he did not remember whether someone was with CNA M when he was lifted from the wheelchair, but he knew CNA L came in to help lay him down and said he was worried about falling during the transfer. RN G, the DON, and the Administrator all stated that residents requiring a mechanical lift should always have two staff assisting, and the facility policy reviewed did not specify how many staff were needed for a mechanical lift transfer.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with chronic respiratory failure, sleep apnea, heart failure, and tracheostomy status. The resident’s care plan required oxygen set at 4 liters per nasal cannula and included tracheostomy-related interventions, including keeping an extra tracheostomy tube and obturator at bedside. Physician orders also directed oxygen at 4 liters per minute via tracheostomy continuously and tracheostomy care every shift and as needed. During observation, the resident was found wearing oxygen at 5 liters per nasal cannula instead of the ordered 4 liters. The resident stated her oxygen should be set at 4 liters. At that time, the resident did not have her extra tracheostomy in the room. She stated the Ambu bag with the extra tracheostomy was in the closet, but the LVN later verified that the Ambu bag and smaller extra tracheostomy were not visible in the room or closet. The LVN then obtained an Ambu bag from about ten feet away and could not locate a size 5.0 tracheostomy in the supply closet. The DON stated the resident should have an Ambu bag on the wall and an extra smaller tracheostomy inside the bag, and that the extra tracheostomy should be size 5.0. The ADON stated the resident should have oxygen, an Ambu bag, a suction machine, a trach collar, a 5.0 tracheostomy, and a tracheostomy kit at bedside. Later, the resident was observed with an Ambu bag and tracheostomy supplies hanging in front of the bed, and the DON stated the 5.0 tracheostomy had been found in an isolation cart. The facility policy stated that a replacement tracheostomy tube and suction equipment must be available at the bedside at all times.
Discontinued antidepressant remained on medication cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident. Resident #50, a female with diagnoses including schizophrenia and major depressive disorder, had a BIMS score of 15 and was dependent on staff for toileting, dressing, and personal hygiene. Her record showed an order for escitalopram oxalate 10 mg daily after a psychiatric visit, and there was no active order for escitalopram oxalate 5 mg. During observation, escitalopram 5 mg and escitalopram 10 mg were both found on the medication cart for Resident #50. RN G stated the 5 mg dose should no longer have been on the cart and that discontinued medication should be removed when a new order is received. RN H said the process was to update the EHR, notify the pharmacy, and remove the discontinued medication from the cart, but he did not remember whether this was done. The DON and Administrator both stated discontinued medications should be removed from the medication cart, and the facility policy stated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Smoking safety evaluations not completed at required intervals
Penalty
Summary
The facility failed to establish and follow smoking policies in accordance with applicable Federal, State, and local regulations for two residents who smoked. The deficiency involved Resident #2 and Resident #55, both of whom were identified in the report as smokers with smoking-related care plan interventions and smoking safety evaluations that were not completed at the required quarterly interval. The facility policy, revised 07/01/25, stated that resident smoking evaluations were to be completed on admit/readmit, quarterly, and with any change in condition. Resident #2 was a male with diagnoses including dementia, diabetes, and high blood pressure. His quarterly MDS dated 11/16/25 showed a BIMs score of 15 and indicated he was cognitively intact, dependent with ADLs, and his care plan identified him as a smoker at risk of injury due to smoking preference. His smoking screen assessment was last dated 4/25/25 and identified him as a safe smoker. During observation on 12/01/25, he was outside smoking with other residents and stated he always kept his own smoking supplies with him. Resident #55 was a female with diagnoses including dementia, TBI, and seizures. Her quarterly MDS dated 09/18/25 showed a BIMs score of 07, indicating severe impairment, and her care plan identified her as a smoker at risk for injury due to smoking preference, with interventions including evaluation of smoking safety abilities and supervision-related measures. Her smoking screen assessment was last dated 03/03/25 and identified her as a safe smoker. During observation on 12/01/25, she was seen going outside with an unlit cigarette in her mouth, took a lighter from her pocket, and lit her cigarette outside. The Social Worker, DON, and Administrator stated they were responsible for or aware of the smoking assessment process and acknowledged the assessments were not being completed at the required frequency.
Failure to Coordinate PASRR Assessments and Timely Provision of Specialized Services
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program and did not incorporate the recommendations from the PASRR evaluation report into the care planning for a resident. Specifically, the care plan identified that the resident, who had diagnoses including muscle weakness, quadriplegia, muscle spasm, and abnormal posture, required specialized services due to mental illness and traumatic brain injury (TBI). The interdisciplinary team (IDT) agreed that the resident needed a specialized or treated pressure-reducing support surface mattress as durable medical equipment (DME), but the facility did not provide or arrange for this service within the required timeframe set by PASRR. Record review and staff interviews revealed that the necessary Nursing Facility Specialized Services (NFSS) form for the DME was not submitted within the 20 business days required after the IDT meeting. The Clinical Reimbursement Coordinator and Corporate Nurse confirmed that the NFSS for the specialized mattress was not submitted until several months after the recommendation, and the facility remained out of compliance. Additionally, the MDS Coordinator reported not having been trained on PASRR, and the facility lacked a policy regarding PASRR coordination at the time of the deficiency.
Failure to Complete Annual Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members completed annual training on resident rights and facility responsibilities, as required by facility policy. Specifically, one LVN, hired in November 2021, had not received the mandatory annual training on resident rights for the period reviewed. This was identified through a review of the facility's mandatory training records and confirmed during an interview with the Administrator, who acknowledged the expectation for all staff to complete required annual training. The facility's policy, revised in September 2022, mandates that all staff participate in both initial orientation and annual in-service training, including training on resident rights and responsibilities.
Failure to Complete Mandatory QAPI Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff completed mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program, as required by facility policy. Record review showed that three employees—a registered nurse, a certified nursing assistant, and a licensed vocational nurse—had not received the required annual QAPI training for the period reviewed. The facility's policy, revised in September 2022, mandates that all staff participate in both initial orientation and annual in-service training, including training on the elements and goals of the QAPI program. During an interview, the Administrator confirmed the expectation that all staff complete mandatory annual training to stay updated and refreshed on required topics.
Failure to Ensure Annual Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that annual Compliance and Ethics training was completed for one of eleven employees reviewed, specifically a registered nurse hired in July 2021. Record review showed that this staff member had not received the required annual training on compliance and ethics for the period from July 2024 through July 2025. Interviews with facility leadership confirmed that all staff were expected to complete mandatory training annually, as outlined in the facility's policy, which requires participation in both initial orientation and annual in-service training, including compliance and ethics program standards. The deficiency was identified through both record review and staff interviews.
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Illustrative
What surveyors actually found near you
We read the 308 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Terrell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Countryview Nursing & Rehabilitation | 1.5 mi | ★★★★★ | 23 | 1 |
| Windsor Rehabilitation And Healthcare | 2.4 mi | ★★★★★ | 21 | 0 |
| Ridgecrest Healthcare And Rehabilitation Center | 9.7 mi | ★★★★★ | 4 | 0 |
| Sunflower Park Health Care | 10.4 mi | ★★★★★ | 19 | 0 |
| Avir At Kaufman | 11.5 mi | ★★★★★ | 19 | 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.