Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Texoma Healthcare Center during CMS and state inspections, most recent first.
Failure to Provide Foot and Nail Care: Two residents did not receive needed foot care. One resident with cognitive impairment and multiple medical diagnoses had dry, flaky feet that staff observed but did not treat with lotion, despite staff acknowledging the condition. Another resident with cerebral palsy and severe cognitive impairment had toenails observed to be about an inch past the nail bed, while staff gave conflicting accounts about who was responsible for trimming non-diabetic residents’ toenails.
Failure to prime insulin pens before administration: an LPN administered sliding-scale insulin to two residents and another LPN administered insulin to a third resident without first priming the pens. The residents had type 2 DM and received Novolin R, Humalog, and Novolog after blood sugar checks, but the nurses dialed in the ordered doses without completing the required priming step. The DON stated the pens were to be primed with 2 units before each injection to ensure the air was out of the pen and the resident received the full amount of insulin.
Food service staff failed to follow basic food safety practices during meal service. The Dietary Mgr was observed checking some foods but not all hot and cold items before service, reusing a thermometer without sanitizing it between foods, and serving chicken strips, fries, and salads without temperature checks. An aide also returned from the pantry, handled food, and continued serving without hand hygiene after glove removal. Facility policies and FDA Food Code guidance required temperature checks, thermometer sanitization, and handwashing during food prep and service.
Multiple infection control failures were observed during resident care. An LVN used a glucometer on one resident and then on another without disinfecting it, and also returned an unsanitized bottle of test strips to the med cart. An RN performed G-tube medication administration without the required gown and gloves, and CNAs provided incontinence care and mechanical lift transfers for a resident on EBP without gowns; another CNA also failed to perform hand hygiene and glove changes during peri-care for a resident, including leaving the room and returning without hand hygiene.
An undated opened vial of Tuberculin Purified protein derivative was found in the ADON’s office refrigerator used for medication storage. The ADON stated the vial had to be dated when opened and was only good for 30 days, while the DON said multiple-use vials were required to be dated once opened and that she and the ADONs were responsible for monitoring medication storage and removing expired medications.
Surveyors identified that kitchen staff failed to consistently record hot and cold food temperatures on required logs, did not maintain cold holding temperatures for milk, and did not follow proper glove use to prevent cross-contamination between raw chicken and ready-to-eat sliced cheese. Temperature logs were incomplete for multiple meals, and milk on prepared trays was found above the required 41°F threshold. A dietary aide handled raw chicken and then touched sliced cheese with the same gloves before serving a meal to a resident, contrary to facility policy and FDA Food Code requirements for single-use gloves and time/temperature control for safety foods.
A resident with dementia, dysphagia, protein-calorie malnutrition, and no teeth had a care plan and orders addressing swallowing problems and diet needs, including a renal diet and prior use of mechanical soft texture. The resident’s meal ticket listed a mechanical soft renal diet with crushed pineapple for dessert, but dietary staff assembled the tray with Nilla Wafer cookies instead, and the tray was passed through nursing and activities without correction. The resident reported lacking teeth and said he could eat the cookies only with enough water and preferred the crushed pineapple listed. Interviews with the Dietary Manager, DOR, RNs, and Regional Nurse showed conflicting information about whether the resident should be on regular vs mechanical soft diet, reliance on communication forms that were not completed or available, and a breakdown in the process for communicating and verifying diet orders between speech therapy, nursing, and dietary, resulting in the dessert not matching the ordered diet on the meal ticket.
Significant ice accumulation on the walk-in freezer door prevented it from latching properly for an extended period. Dietary staff had to manually de-ice the freezer daily, and there was no written schedule or log for this task. Despite recent repairs to the door handle and seal, the issue persisted, and maintenance was unaware of the ongoing problem. The facility lacked a specific policy for freezer maintenance, contributing to the deficiency.
A treatment nurse failed to perform hand hygiene between glove changes and after removing gloves while providing wound care to a resident with a pressure wound and multiple comorbidities. The nurse handled wound care supplies and personal items without sanitizing hands as required by facility policy, only washing hands at the end of the procedure.
A resident with severe cognitive impairment and multiple comorbidities was given a shower by two CNAs despite repeatedly refusing and expressing distress. The CNAs physically transferred the resident and proceeded with the shower, disregarding her care plan and facility protocols that required staff to honor refusals and notify a nurse. The incident was confirmed by the resident, her roommate, and staff interviews, and resulted in significant emotional distress for the resident.
Two residents with severe cognitive impairment and mental health needs experienced mental anguish when one was physically forced by CNAs to shower despite repeated refusals, and the other was upset after overhearing the incident. Both residents' care plans included trauma-informed interventions and the right to refuse care, but staff proceeded with the shower regardless, resulting in documented distress.
Several residents' care plans did not reflect their preferences for bed baths or their repeated refusals of showers, even though staff were aware and had documented refusals elsewhere. Additionally, a resident with declining vision and a need for cataract surgery did not have her vision needs or related care documented in her care plan, despite ongoing efforts to arrange appointments. These omissions resulted in care plans that did not accurately describe the services to be provided, as required by facility policy.
A facility failed to maintain an effective pest control program, resulting in recurring ant infestations in resident rooms, common areas, and the exterior perimeter. One resident with multiple health conditions was bitten by ants found in her room and bed. Staff used a QR code system to report pest issues, but these were not consistently communicated to the pest control company, and the facility lacked a written pest control policy. The pest control company was not always informed of all pest-related work orders, leading to ongoing pest problems.
A resident with multiple chronic conditions and cognitive impairment experienced a decline in vision and was identified as needing cataract surgery, but the facility did not complete a comprehensive significant change assessment within the required timeframe. The resident's MDS and care plan did not reflect her vision issues, and staff interviews revealed a lack of documentation and understanding regarding the assessment and reporting of vision impairment.
A controlled medication blister pack on a nurses cart was found with a broken seal and the pill still inside, taped over, rather than being discarded as required. The RN responsible did not check blister pack integrity during narcotic counts and was unaware of when the seal was broken. The DON confirmed that such medications should be discarded and that staff are responsible for checking for broken seals during shift changes.
A deficiency was identified when the ice machine's drip tray in the dining room was found with grayish slime, mold, and a used, soaked paper napkin, indicating a failure to follow professional standards for food service safety. Staff interviews revealed uncertainty about the last cleaning, and cleaning logs showed inconsistent adherence to the required daily sanitation schedule.
The facility failed to provide weekend activities for residents, leading to boredom and lack of socialization. Nine residents reported no activities on weekends except for church services. The Activities Director cited the absence of an Activities Assistant since August 2024 as a reason for the deficiency. The facility's policy requires ongoing activities based on residents' interests, but records showed several weekends with no planned activities. Bed-bound residents also reported not being offered one-on-one activities.
A facility failed to provide necessary wound care to three residents, leading to a deficiency in care. A resident with pressure ulcers did not receive treatment for two days, confirmed by both the resident and treatment nurse. Another resident with a stage 3 ulcer also missed care on the same days, despite usually receiving daily treatment. A third resident, at high risk for ulcers, did not have his wound treated, and the missing dressing was noted by staff. The LVN responsible admitted to not completing the care and not seeking help.
The facility failed to accommodate the food preferences of two residents, leading to dissatisfaction with meals. A resident with diabetes and malnutrition reported receiving the same breakfast daily without choice, while another resident received sausage despite preferring bacon. Staff interviews revealed a lack of communication and adherence to resident preferences, contradicting facility policy.
The facility's kitchen failed to store, label, and date food items in accordance with professional standards, as observed in the walk-in refrigerator. Items such as hamburger patties, onions, carrots, cheese slices, and tortillas were not properly managed, posing a risk of cross-contamination. The Dietary Manager and kitchen staff acknowledged their responsibility for these tasks, which are crucial for preventing foodborne illnesses.
A resident with cognitive impairment and medical needs did not receive scheduled showers, as documented in the facility's records. Staff interviews revealed lapses in communication and documentation, with a CNA forgetting to shower the resident and another staff member incorrectly documenting care. The DON acknowledged the responsibility of CNAs and charge nurses to ensure showers were given and documented, noting the risk of skin issues and loss of dignity.
A resident with a gastrostomy tube was observed receiving a water flush at 60 ml/hr instead of the prescribed 50 ml/hr, posing a risk of hydration concerns. The RN confirmed the discrepancy, and the DON emphasized the importance of matching tube feed pump settings with physician orders.
A facility failed to provide proper pharmaceutical services, resulting in medication errors for two residents. An LVN did not prime an insulin pen before administering it to a resident with diabetes, risking incomplete dosage. Another resident, receiving nutrition via a G-tube, was given combined medications against facility policy, which requires separate administration with water flushes. The facility's DON and Pharmacy Consultant confirmed the importance of following these procedures to ensure accurate medication delivery.
A resident with severe cognitive impairment and multiple medical conditions was transported to the hospital after becoming unresponsive, but the facility failed to immediately notify the resident's representative. The resident's representative was informed by the hospital days later, impacting her ability to make timely medical decisions. The failure occurred because the responsible RN forgot to contact the family at the end of her shift.
Two residents in an LTC facility did not receive scheduled showers, leading to a deficiency in care. A moderately cognitively impaired female and a severely cognitively impaired male were both scheduled for regular showers but did not receive them consistently. Staff interviews revealed issues with documentation and communication, resulting in missed showers. The facility's policy on bathing was not followed, risking skin issues and loss of dignity for the residents.
A resident did not receive several medications upon admission due to the facility's failure to order them in a timely manner. The medications were not available in the emergency kit, and the pharmacy was not contacted after hours to expedite the order. The resident, who was severely cognitively impaired and had multiple diagnoses, missed doses of important medications, highlighting a lapse in the facility's pharmaceutical services.
Failure to Provide Foot and Nail Care
Penalty
Summary
The facility failed to ensure proper foot care for Resident #23, a moderately cognitively impaired female with diagnoses including a closed fracture of the neck of the left femur, chronic heart failure, and acute respiratory failure with hypoxia. During observation, both feet were noted to be white, dry, and flaky, especially near the toes. Resident #23 stated staff had not applied lotion to her feet and said she would like them to. She also stated a podiatrist had not seen her at the facility. LVN N acknowledged seeing the edema and dry, flaky skin on Resident #23’s feet since admission and stated she should have gotten lotion for the resident to help with the condition. The LVN also stated the facility had lotion available or could have contacted the doctor for a prescription for lotion for residents with dry, flaky skin. The DON stated CNAs were expected to apply lotion when they noticed dry, flaky skin and said the facility did not have in-house lotion available for shower days and as needed. The DON stated the risk was that the skin could remain dry and flaky and could lead to more skin concerns. The facility also failed to ensure Resident #35 received toenail care. Resident #35 was a male with cerebral palsy, lack of coordination, muscle weakness, convulsions, and moderate intellectual disabilities, and his MDS reflected severe cognitive impairment and dependence for personal hygiene. His care plan included checking nail length and trimming nails on bath day and as necessary. During observation, his toenails were about an inch longer than the nail bed. Staff interviews showed confusion about responsibility for toenail care, with some CNAs believing a podiatrist should cut the toenails and others stating CNAs were responsible unless the resident was diabetic. The DON stated CNAs were responsible for nail care for non-diabetic residents and that finger and toenails should be cut or trimmed as needed on shower days.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquisition and administration of insulin for three residents with type 2 diabetes mellitus. Resident #9 had an order for Novolin R sliding-scale insulin, Resident #96 had an order for Humalog KwikPen sliding-scale insulin, and Resident #69 had an order for Novolog FlexPen sliding-scale insulin. During observation, LVN E obtained blood sugars for Resident #9 and Resident #96, checked the computer for the ordered doses, and administered insulin without first priming either pen before dialing in the prescribed units. For Resident #9, LVN E obtained a blood sugar reading of 204 and administered 5 units of Novolin R without priming the pen. For Resident #96, LVN E obtained a blood sugar reading of 214 and administered 3 units of Humalog without priming the pen. During interview, LVN E stated she only primed insulin pens when they were first opened and was not aware they needed to be primed each time. She stated the purpose of priming was to ensure the insulin was all the way to the end of the pen and that she would always prime the pen going forward. For Resident #69, LVN D obtained a blood sugar reading of 476, determined the resident would receive 20 units of Novolog, and then administered the insulin without first priming the pen. LVN D stated she forgot the step and was supposed to prime the pen with 2 units to ensure the air was out of the pen and to make sure the resident received the full amount of insulin prescribed. The DON stated the insulin pen was to be primed with 2 units before each injection to ensure the air was out of the pen and to determine if it was working correctly, and that failure to do so could result in the resident receiving too little medication.
Food Temperature Checks, Thermometer Sanitization, and Hand Hygiene Lapses During Meal Service
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the kitchen. During lunch meal service, the Dietary Manager was observed taking the temperature of gumbo, wiping the thermometer with a sanitizing pad, and then placing the thermometer on the counter before using it again on rice and corn bread without sanitizing it between foods. The Dietary Manager later poured chicken strips and French fries from the fryer into warming trays without being observed taking their temperatures, and plates with salads were served without the salads being temperature checked. Chicken strips and French fries were also served from the warming table without temperature checks. During the same meal service, Dietary Aide B stopped serving food, went to the pantry to get hamburger buns, and returned with a box of gloves. She put on one glove, handled a hamburger bun, removed the glove, and continued serving food without washing or sanitizing her hands after returning from the pantry or after removing the glove. The Dietary Manager stated that all hot and cold foods should have been temperature checked before serving, that the thermometer should have been sanitized before and after each food and after being placed on a surface, and that staff should have washed hands after leaving the serving area and returning or after removing gloves. Record review showed two anonymous grievances alleging food was always undercooked, especially on weekends. The facility’s Infection Control policy required careful hand washing in specified situations, and the Daily Food Temperature Control policy required temperatures of all hot and cold foods to be taken prior to every meal service and recorded, with the thermometer sanitized between food testing. The FDA Food Code excerpts reviewed by surveyors also addressed when food employees must wash hands and the sanitization of food-contact surfaces and utensils.
Infection Control Failures During Glucose Checks, EBP Care, and Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program during multiple observed resident care activities involving blood glucose monitoring, Enhanced Barrier Precautions (EBP), and incontinence care. One licensed vocational nurse obtained a fingerstick blood sugar on one resident, returned the used glucometer to the medication cart without disinfecting it, and then used the same contaminated glucometer for another resident before placing it back in the cart again. The same nurse also carried a bottle of test strips into another resident’s room, placed the bottle on the bedside table, and returned it to the medication cart without sanitizing it first. The facility also failed to ensure EBP were used during high-contact care for residents with wounds or feeding tubes. An RN performed G-tube medication administration and bolus feeding for a resident with Alzheimer’s disease and dysphagia while an EBP sign was posted and gowns were available in the room, but the RN did not wear gloves or a gown. In another room, two CNAs provided care to a resident with wounds and EBP in place, including placing a clean brief and using a mechanical lift, but they did not wear gowns. On a later observation, the same resident was again provided incontinence care and a mechanical lift transfer without gowns, and a soiled brief with bowel movement and multiple soiled wipes were left on the floor before being placed in the trash. The facility further failed to ensure proper hand hygiene and glove changes during incontinence care for another resident. Two CNAs performed peri-care, but one CNA left the room to get more supplies without performing hand hygiene, returned and resumed care without hand hygiene, used the same gloves to apply barrier cream, and then re-gloved without hand hygiene before placing a clean brief. The DON stated staff were expected to change gloves and perform hand hygiene after incontinence care and before moving from dirty to clean tasks, and that residents with wounds, catheters, or G-tubes required gown and glove use during high-contact care. The report also included the facility policy statements on hand hygiene, cleaning resident care equipment, and EBP for residents with wounds or feeding tubes.
Undated Tuberculin Vial in Medication Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and state laws, including the required accessory and cautionary instructions and expiration date when applicable. During observation, surveyors found an undated opened vial of Tuberculin Purified protein derivative in the ADON C office refrigerator used for medication storage. The vial had been filled on 07/22/25, but there was no date showing when it had been opened. During interview, the ADON stated the Tuberculin Purified protein derivative had to be dated when opened and was only good for 30 days after opening. She stated she could not recall the last time it was used and said she would discard the vial because there was no way to know how long it had been opened. The DON stated she and the ADONs were responsible for monitoring medication storage areas and refrigerators to ensure expired medications were removed from possible use, and that any multiple-use vial was required to be dated once opened. Record review of the facility’s medication storage policy stated medications and biologicals are to be stored safely, securely, and properly following manufacturer recommendations or those of the supplier, and that outdated, contaminated, or deteriorated medications are to be immediately removed from stock.
Failure to Maintain Food Temperatures and Prevent Cross-Contamination in Kitchen
Penalty
Summary
The deficiency involves failures in food storage, preparation, and handling practices in the facility’s only kitchen, specifically related to temperature monitoring and cross-contamination prevention. During an observation of the kitchen, the surveyor requested hot and cold food temperature logs and found that temperatures were not thoroughly taken or recorded on multiple dates for various food items, including milk and juice beverages, side dishes of fruits and vegetables, and meat entrées. The Dietary Manager acknowledged the incomplete temperature logs and stated that bolded items on the log were supposed to be temperature checked, and that hot foods must be 145°F and higher and cold foods 41°F and lower to prevent spread of illness and contamination. Facility policy required temperatures of all hot and cold foods to be taken prior to every meal service and recorded on the Temperature Log, with hot foods held at 140°F or above and cold foods less than 41°F. Further observations during lunch preparation showed that staff did not consistently maintain cold holding temperatures and did not follow proper glove use to prevent cross-contamination. Two lunch trays were observed with cups of milk that were not held to maintain cold temperatures, and when the milk temperature was checked, it measured 52.7°F. In another observation, a dietary aide donned new gloves to handle raw chicken tenders and, without changing gloves, then touched sliced cheese and placed it on a hamburger intended for a resident. When questioned, the dietary aide stated that touching raw meat and then sliced cheese could get someone sick. The facility’s written procedures and the referenced FDA Food Code required single-use gloves to be used for only one task, such as working with raw animal food or ready-to-eat food, and required time/temperature control for safety foods to be maintained at 135°F or above for hot holding and 41°F or less for cold holding.
Failure to Follow Ordered Diet Texture and Dessert for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided met professional standards of quality by not following the comprehensive care plan and diet orders for one resident. The resident was an older man with dementia with psychotic disturbance, dysphagia, and unspecified protein-calorie malnutrition, and required dentures. His care plan identified a potential nutritional problem and a swallow problem related to dysphagia, with instructions for staff to monitor for swallowing difficulties and to ensure the prescribed diet was followed, with goals of no choking episodes and no signs of aspiration. Record review showed an active physician order for a renal diet with regular texture and regular consistency, and a discontinued order for a renal diet with mechanical soft texture. However, during meal tray preparation, the resident’s meal ticket listed a renal diet with mechanical soft texture and specified a dessert of 1/2 cup crushed pineapple. Instead of the ordered crushed pineapple, the tray was assembled with a cup of Nilla Wafer cookies as dessert and passed from dietary to an RN and then to the activities director for delivery. When observed, the resident, who did not have teeth, stated he could eat the cookies only if he drank enough water and indicated he preferred the crushed pineapple listed on his meal ticket. Interviews revealed inconsistent understanding and communication of diet orders among staff. The Dietary Manager stated that Nilla Wafers were considered safe for mechanical soft diets when served with pudding and that dietary staff relied on written communication forms from nursing or speech therapy for diet changes; he reported having no such form for this resident. The Director of Rehabilitation stated the resident had been evaluated by speech therapy and was on a regular diet with thin liquids, and that speech therapy did not communicate diet orders directly to the kitchen, expecting nursing to complete and deliver diet order forms. RN A reported relying on dietary staff’s statement that Nilla Wafers were mechanical soft, was unaware of the regular diet order in the chart, and described a process in which nursing created and sent diet sheets to dietary. RN B stated the resident could eat a regular diet but was supposed to be on mechanical soft due to not using dentures, and did not recall completing a communication form for a regular diet order. The Regional Nurse described expectations that dietary staff and nurses check meal tickets and meals before delivery and that speech-initiated diet changes be entered into the chart and confirmed by nursing before being sent to dietary, underscoring that this process was not effectively followed for this resident’s dessert.
Failure to Maintain Walk-In Freezer in Safe Working Condition
Penalty
Summary
Surveyors observed significant ice accumulation on the walk-in freezer door, with ice measuring 1 to 3 inches in width and covering various parts of the doorway, preventing the door from latching properly. Dietary staff reported that the issue had persisted for about two months and had worsened in the last month, requiring them to manually de-ice the freezer daily. The inability to latch the freezer door was directly attributed to the ice buildup, and staff confirmed that the door could not be closed fully due to this accumulation. The Dietary Manager acknowledged that the excess ice and inability to latch the door placed food at risk for contamination, freezer burn, and deterioration, and also confirmed there was no log or written schedule to ensure regular de-icing by staff. Maintenance records indicated that while the door handle and seal had been replaced, the problem persisted, and a contractor had not yet completed necessary repairs. The Maintenance Supervisor was unaware that the door was still not latching properly. Review of facility policy showed that while there was a policy for refrigerator maintenance, there was no specific policy for freezer maintenance or storage. The lack of a clear maintenance protocol and failure to ensure the freezer door could latch properly led to ongoing ice accumulation and potential food safety risks.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for one resident. During an observed wound care procedure, the treatment nurse did not perform hand hygiene between glove changes or after removing gloves, despite handling various supplies and touching the resident's wound. The nurse also did not use hand sanitizer prior to entering the resident's room or after removing gloves at several points during the procedure. The nurse handled items such as a tube of medicated ointment, gauze, dressings, and a marker without performing hand hygiene between tasks, and only washed her hands at the end of the procedure after disposing of trash. The resident involved was an elderly male with a history of a left femur fracture, hypertension, and chronic kidney disease, and had a pressure wound on his left heel. The resident had severely impaired cognition and required wound care as part of his treatment plan. The facility's infection control policy required hand hygiene before and after changing dressings and after removing gloves, but these protocols were not followed during the observed wound care event.
Resident's Right to Refuse Shower Not Honored
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic pain syndrome, and anxiety disorder was not treated with respect and dignity regarding her right to refuse care. On the evening in question, the resident verbally refused a shower multiple times, stating she was cold and did not want a shower. Despite her refusals, a CNA physically lifted her from the bed by her armpits, placed her in a shower chair, and, with the assistance of another CNA, proceeded to shower her. The resident continued to express her refusal and distress throughout the process, including stating she would contact her attorney and the police. The resident's care plan specifically included interventions to immediately stop if she refused a shower, and to avoid touching her if she was escalated, unless necessary for safety. Multiple interviews and record reviews confirmed that the resident was able to communicate her wishes and had the capacity to make informed decisions. Staff statements and documentation indicated that the CNAs were aware of the resident's right to refuse a shower and the facility's policy for handling refusals, which included notifying a nurse and completing a refusal form. However, the CNA disregarded these protocols, insisting the resident would feel better after a shower and proceeding without her consent. The incident was corroborated by the resident's roommate, who overheard the exchange, and by subsequent interviews with other staff members who acknowledged that forcing a resident to shower against their will was a violation of resident rights. The event resulted in the resident feeling angry and distraught, as documented in her statements to staff, the social worker, and a psychologist. The resident reported the incident to her nurse, family, and external parties. Progress notes and interviews indicated that the resident had no physical injuries directly attributed to the incident, but she experienced significant emotional distress. The facility's policies on resident rights and bathing clearly outlined the necessity of honoring resident preferences and refusals, but these were not followed in this instance, leading to the identified deficiency.
Failure to Prevent Abuse and Honor Resident Refusals During Showering
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically for two residents with severe cognitive impairment and mental health diagnoses. One resident, who had a history of trauma, chronic pain, COPD, Alzheimer's disease, and anxiety disorder, was physically lifted from her bed by a CNA under her armpits and given a shower despite her repeated verbal refusals. The resident expressed anger and mental anguish as a result of being forced to shower against her will. Documentation and interviews confirmed that the resident was able to communicate her wishes and had the capacity to make informed decisions at the time of the incident. Another resident, who was the roommate of the first, also experienced mental anguish after overhearing the incident. This resident, who had diagnoses including cancer, heart failure, stroke with paralysis, and major depressive disorder, reported being upset by hearing her roommate being forced to shower by staff. Both residents were on mental health services, and their care plans included interventions for cognitive impairment and trauma-informed care, including respecting refusals and stopping care if the resident became escalated. Staff interviews and record reviews revealed that the CNAs involved were aware of the residents' right to refuse care but proceeded with the shower regardless. The incident was reported by the affected resident to nursing staff and was corroborated by her roommate and other staff members. The event was documented in progress notes, care plans, and verbal statements, and was identified as Immediate Jeopardy Past Noncompliance by surveyors. The actions of the staff directly contradicted the residents' expressed wishes and established care plan interventions, resulting in documented mental distress for both residents.
Failure to Include Resident Preferences and Vision Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately described the services to be furnished to meet the highest practicable physical, mental, and psychosocial well-being of four residents. Specifically, the care plans did not reflect the residents' preferences and needs regarding bathing and vision care. For three residents with severe cognitive impairment and significant physical limitations, their repeated refusals of showers and preferences for bed baths were not documented in their care plans, despite staff being aware of these preferences and having residents sign shower refusal forms. Interviews with staff confirmed that these residents commonly refused showers, and the process for documenting refusals was inconsistently followed, with some refusal forms missing from the medical records. Additionally, one resident with a history of cataracts and declining vision did not have her vision needs or the need for eye care and surgery reflected in her care plan. Although there were physician orders and ongoing efforts by the social worker to arrange necessary eye appointments and surgery, these needs were not documented in the care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's vision impairment, and the care plan did not include interventions or plans to address her vision needs. The facility's policies required that care plans be person-centered and include measurable objectives and timeframes to meet residents' identified needs. However, the care plans reviewed did not include the residents' preferences for bathing or their vision care requirements, despite these being known to staff and relevant to the residents' well-being. This omission resulted in care plans that did not fully describe the services to be provided, as required by facility policy and regulatory standards.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, resulting in the presence of ants in resident rooms, on the exterior perimeter of a resident hall, and in multiple locations throughout the building. In one instance, a resident with multiple medical conditions, including hypertension, diabetes, and a surgical site, was found to have ants in her room and on her bed, leading to two pinpoint bites on her thighs. The nurse who discovered the ants noted that the insects were coming from the window seal, and the resident had open food in the room at the time. Documentation confirmed the presence of ant bites, and the resident was subsequently moved to another facility. Observations and interviews revealed that an ant hill was present on the exterior perimeter near a resident hall, close to a resident room window. The Maintenance Director acknowledged the ant hill and reported an increase in work orders for ants, attributing it to hot weather. The facility's pest control company provided monthly services and responded to additional requests, but the pest control binder and maintenance logs were not consistently shared with the pest control company. The Maintenance Director handled most complaints internally and did not provide the maintenance log, which tracked pest-related work orders, to the pest control company. This lack of communication limited the pest control company's awareness of all pest issues in the facility. Record reviews showed multiple entries in both the pest control binder and the maintenance task report documenting recurring ant problems in various rooms and common areas. Staff interviews indicated that pest sightings were reported through a QR code system, but these reports were not always transferred to the pest control binder or communicated to the pest control company. The facility did not have a written pest control policy, and the Administrator confirmed that logs from the QR code system were not routinely provided to the pest control company. The absence of a comprehensive and coordinated pest control program resulted in ongoing pest issues and placed residents at risk for infection and decreased quality of life.
Failure to Complete Significant Change Assessment for Vision Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition, specifically a decline in vision, was comprehensively assessed within 14 days as required. The resident, an older adult with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Cognitive Communication Deficit, was noted in a physician's progress note to have cataracts and was recommended for follow-up with an ophthalmologist for possible surgery. Despite this, the resident's Quarterly MDS assessment did not reflect any vision impairment or use of corrective lenses, and her care plan did not mention vision issues or the need for eye care or surgery. Interviews and record reviews revealed that the resident expressed difficulty seeing, required eyeglasses, and reported urgent need for an eye doctor due to declining vision. The social worker made several attempts to arrange an eye exam and surgery, but was unsuccessful due to transportation challenges related to the resident's size and a fall during a previous transport attempt. These efforts were not documented in writing. The MDS nurse stated that vision issues were not included in the MDS because there was no formal diagnosis from an eye doctor, despite a nurse practitioner's note mentioning cataracts. Other staff, including the ADON and Administrator, were either unaware of the vision decline or unsure of the requirements for documenting vision impairment in the MDS. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual. The DON acknowledged that vision impairment should be noted on the MDS and that failure to do so could result in the resident not receiving necessary eye care. The RAI Manual outlines the importance of assessing and documenting vision impairment and the use of corrective lenses, but these steps were not followed for this resident, resulting in the deficiency.
Failure to Properly Label and Secure Controlled Medications on Nurses Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on the D hall Nurses Cart were not labeled and stored in accordance with professional standards. Specifically, a blister pack containing APAP/codeine 300-30 mg tablets for a resident had one blister seal broken, with the pill still inside and taped over. The RN responsible for the cart stated that while narcotic counts were performed at shift change, she did not check the integrity of the blister packs during the count and was unaware of when or how the seal was broken. The RN acknowledged that nurses are responsible for checking for broken seals during shift changes and that any broken-seal medication should be wasted with another nurse present. The DON confirmed that any medication with a broken blister pack seal should be discarded and that it was not acceptable to keep a pill in an opened blister pack, citing risks of drug diversion and infection control. The DON also stated that nurses are responsible for checking medication blister packs during shift changes and that ADONs are expected to randomly monitor the carts. Facility policy requires that medications in containers without secure closures be immediately removed and disposed of according to procedures.
Failure to Maintain Sanitary Conditions of Ice Machine
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically regarding the cleanliness and sanitation of the dining room's ice machine. During observation, the ice machine's drip tray was found to have a buildup of grayish slime or mold and contained an old, used, and soaked paper napkin. The dietary staff member interviewed was unable to recall the last time the machine had been cleaned and sanitized and had to refer to the daily cleaning schedule log. The cleaning schedule indicated that the ice machine was supposed to be sanitized daily before each meal, but the log showed inconsistent cleaning dates over a two-week period. Interviews with staff, including the dietary staff and the administrator, confirmed that it was the responsibility of dietary, housekeeping, and administrative staff to ensure the beverage bar machines, including the ice machine, were kept clean and sanitized. The facility's policy required the ice machine to be cleaned and sanitized according to the manufacturer's instructions to prevent food contamination and the growth of disease-producing organisms. The observed failure to maintain the ice machine in a sanitary condition placed residents at risk of food contamination and foodborne illness.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide activities that meet the interests and support the physical, mental, and psychosocial well-being of residents during weekends. This deficiency was identified through observations, interviews, and record reviews, revealing that nine residents did not have access to weekend activities, except for church services on Sundays. The lack of weekend activities was confirmed during a group interview with residents who expressed boredom and a desire for more activities on Saturdays and Sundays. The Activities Director acknowledged the absence of weekend activities, attributing it to the departure of the Activities Assistant in August 2024. Since then, the facility has struggled to offer consistent weekend activities. The Activities Director mentioned that activities of resident choice were listed on the calendar for weekends, but these primarily involved residents playing games they already owned. The Solarium provided puzzles and books, but there were no organized activities facilitated by staff or volunteers on weekends, except for occasional events like church group visits or activities led by the Activities Director herself. Interviews with the Administrator and record reviews further highlighted the issue. The Administrator stated there were no plans to hire a new Activities Assistant and acknowledged the risk of boredom and lack of socialization for residents. The facility's policy on activity programming emphasized the need for ongoing activities based on residents' interests, but the records showed several weekends with no planned activities. Additionally, bed-bound residents reported not being offered one-on-one activities, although they had access to some in-room materials.
Failure to Provide Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment to three residents, leading to a deficiency in the quality of care. Resident #82, a moderately cognitively impaired male with diabetes and a history of hip replacement surgery, had two pressure ulcers upon admission. His treatment plan required wound care twice daily, but no treatment was provided on two consecutive days. The resident confirmed that the staff did not treat his wound during the specified times, and the treatment nurse later confirmed the lapse in care. Resident #21, a cognitively intact female with diabetes, heart failure, and a seizure disorder, had a stage 3 pressure ulcer and other skin damage. Her treatment plan required daily wound care, which was not administered on the same two days as Resident #82. The resident noted the unusual absence of her wound care over the weekend, despite typically receiving it daily. The treatment nurse observed minimal drainage from the resident's wound, indicating a lack of recent care. Resident #85, a cognitively intact male with heart failure and malnutrition, was at high risk for pressure ulcers. His treatment plan required daily wound care for an ulcer on his coccyx, but no care was provided on the same two days as the other residents. The Assistant Director of Nursing (ADON) was alerted to the missing dressing on the resident's wound, and it was confirmed that the wound care was not performed. The Licensed Vocational Nurse (LVN) responsible for the lapse admitted to not completing the wound care and failing to seek assistance, leading to the deficiency.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodates resident preferences for two residents, leading to dissatisfaction with meals. Resident #76, a moderately cognitively impaired male with diabetes and malnutrition, expressed dissatisfaction with the repetitive breakfast menu and lack of choice. Despite being on a regular texture diet, he reported receiving the same breakfast items daily without being consulted on his preferences. The Dietary Manager admitted to making menu changes without resident input, and the dietician was unaware of the residents' complaints. Resident #31, also moderately cognitively impaired with diabetes and hyperlipidemia, reported receiving sausage daily despite her preference for bacon. She expressed confusion over the lack of variety and the facility's failure to honor her requests consistently. The facility's weekly menu for November showed the same breakfast items daily, contradicting the policy that requires offering a variety of food and accommodating resident preferences. Interviews with staff revealed a lack of communication and adherence to resident preferences. The Dietary Manager and Administrator acknowledged the repetitive breakfast menu but did not ensure residents were informed of changes or given choices. The facility's policy requires documenting menu changes and offering alternatives, but this was not consistently practiced, leading to potential dissatisfaction and poor intake among residents.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the walk-in refrigerator were not properly covered, labeled, or dated. This included hamburger patties, sliced raw onions, petite cut carrots, cheese slices with mold-like growth, and tortillas. These lapses were identified during an observation on November 18, 2024, at 7:50 AM. The Dietary Manager acknowledged that the responsibility for dating and labeling food items fell on both the cooks and himself, and he confirmed that the expectation was for all food items to be marked with a received date and a use-by date for leftovers and opened items. Interviews with kitchen staff, including a dietary aide and a cook, revealed that they were aware of the importance of covering, dating, and labeling food items to prevent cross-contamination and potential foodborne illness. The facility's policy on food safety, although undated, required that all food be wrapped or sealed, labeled, dated, and stored properly, with perishable opened foods to be used within seven days. The Food and Drug Administration Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food must be clearly marked with a date or day by which it should be consumed, sold, or discarded.
Inconsistent Hygiene Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received consistent hygiene care, specifically showers or baths. The resident, a moderately cognitively impaired male with a BIMS score of 10, required substantial to maximum assistance with bathing due to his medical conditions, including diabetes and aftercare following hip replacement surgery. Despite being scheduled for showers on specific days, the resident did not receive showers on multiple occasions in November 2024, as documented in the facility's records. Interviews with the resident and staff revealed that the resident had only received one shower in a week and had to request it multiple times. Staff interviews indicated lapses in communication and documentation. A CNA admitted to forgetting to shower the resident and failing to document a refusal when the resident declined a shower at a later time. Another staff member incorrectly documented that the resident received a shower, despite not providing it. The facility's DON acknowledged the responsibility of CNAs and charge nurses to ensure showers were given and documented, and noted the risk of skin issues, hygiene problems, and loss of dignity for residents not receiving scheduled showers. The facility's policy emphasized the importance of regular bathing for maintaining skin integrity and cleanliness.
Incorrect Water Flush Administration for Enteral Nutrition
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was administered the correct water flush as per the physician's orders. The resident, a male with multiple health conditions including hypertension, cerebrovascular accident, gastrostomy status, malnutrition, respiratory failure, and aphasia, was observed to have a tube feeding pump set to deliver a water flush at 60 ml/hr instead of the prescribed 50 ml/hr. This discrepancy was noted during an observation and interview with a registered nurse (RN), who confirmed that the pump settings did not match the physician's orders. The RN acknowledged that the incorrect settings posed a risk of hydration concerns and decreased quality of care for the resident. The Director of Nursing (DON) also stated that the expectation was for the tube feed pump settings to match the physician's orders and that all nurses were responsible for ensuring the accuracy of the tube feeding infusions. The facility's policy on enteral nutrition emphasized providing nutritionally complete feedings as ordered by the physician, highlighting the importance of adhering to prescribed orders to prevent complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. For Resident #15, a cognitively intact female with diabetes mellitus, the Licensed Vocational Nurse (LVN) did not follow the manufacturer's instructions for the Lantus Insulin Pen. The LVN administered 20 units of insulin without priming the pen, which is necessary to ensure the removal of air and the delivery of the full dose. The LVN acknowledged awareness of the priming requirement but failed to perform it during the medication pass. For Resident #97, a moderately cognitively impaired female receiving nutrition through a feeding tube, the LVN did not adhere to physician orders and facility procedures for administering medications. The LVN combined Sertraline and Levothyroxine in one medication cup, contrary to the requirement to administer each medication separately with a water flush in between. Although the LVN corrected the administration of other medications, she did not separate the Sertraline and Levothyroxine, citing the small volume of Levothyroxine as the reason. The facility's Pharmacy Consultant confirmed that best practice is to administer each medication separately to avoid potential incompatibility issues. Interviews with the Director of Nursing (DON) and the Pharmacy Consultant highlighted the importance of following established procedures to ensure residents receive the correct medication dosages. The DON emphasized that the facility's policy requires individual administration of medications with water flushes between each when using a G-tube, unless otherwise ordered by a physician. The failure to adhere to these procedures could result in residents not receiving the full amount of medication ordered.
Failure to Notify Resident's Representative of Emergency Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who was transported to the hospital via ambulance after becoming unresponsive. The resident, a male with severe cognitive impairment and multiple medical conditions including cerebral infarction, metabolic encephalopathy, and chronic obstructive pulmonary disease, was found somnolent and minimally responsive by RN-A, who then contacted the physician and arranged for emergency transport. Despite the critical nature of the situation, the resident's representative was not informed by the facility until several days later, after the hospital had already contacted her. The resident's representative was informed by the hospital that the resident was on a ventilator and had significant medical issues, including imbalances in sodium and blood sugar levels, and an elevated white blood count. The facility's failure to notify the family immediately could have impacted the ability of the resident's representative to make timely medical decisions. Interviews with facility staff, including RN-A and the Assistant Director of Nursing, revealed that the notification failure was due to RN-A forgetting to contact the family at the end of her shift. The facility's policies on family notification and resident rights emphasize the importance of timely communication with resident representatives in the event of significant changes in condition, but these procedures were not followed in this instance.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically showers and baths, for two residents who were unable to perform these tasks independently. Resident #2, a moderately cognitively impaired female with a history of stroke and joint replacement surgery, was scheduled to receive showers three times a week but did not receive them on multiple occasions throughout July 2024. Despite being scheduled for showers, the resident reported going over two weeks without one, citing a lack of towels and washcloths as reasons given by aides. Interviews with staff revealed inconsistencies in documentation and communication regarding the resident's care. Resident #3, a severely cognitively impaired male with dementia and chronic kidney disease, also did not receive scheduled showers on numerous occasions in July 2024. The resident expressed that he had not been receiving his showers as scheduled, and observations confirmed he was wearing the same clothing over consecutive days. Staff interviews indicated a lack of clarity and communication about who was responsible for providing the resident's showers, with aides assuming others had completed the task and failing to document or report missed showers to the charge nurse. The facility's policy on bathing, which emphasizes the importance of maintaining hygiene and skin integrity, was not adhered to, as evidenced by the lack of consistent bathing for these residents. The Director of Nursing acknowledged the responsibility of CNAs and charge nurses to ensure residents receive their scheduled showers and the importance of documenting any refusals or missed care. The failure to provide consistent hygiene care could lead to skin issues, hygiene problems, and a loss of dignity for the residents involved.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in missed doses of several medications. Upon admission, the resident did not receive Anastrozole, Liothyronine Sodium, Bupriopion HCL ER, Cefadroxil, and Propranolol as ordered by the physician. This was due to the facility staff not ordering the medications in a timely manner, leading to their unavailability when needed. The resident, who was severely cognitively impaired and had a history of malignant neoplasm, was admitted with diagnoses including hypertension, hypothyroidism, a bacterial infection, and PTSD. The facility's staff failed to ensure that the medications were ordered and available upon the resident's admission, which resulted in missed doses the following morning. The medications were not available in the emergency kit, and the pharmacy had not been contacted after hours to expedite the order. Interviews with facility staff and the contracted pharmacy revealed that the facility had recently changed pharmacies and was still adjusting to the new procedures. The staff did not follow the protocol of calling the pharmacy after hours to ensure timely delivery of medications. The Director of Nursing acknowledged the oversight and noted that the pharmacy procedure was posted at each nurse's station, outlining the ordering protocol.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 99 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sherman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Sherman | 0.6 mi | ★★★★★ | 5 | 0 |
| Focused Care At Sherman | 2.9 mi | ★★★★★ | 3 | 0 |
| Beacon Hill | 4.2 mi | ★★★★★ | 10 | 0 |
| Cedar Hollow Rehabilitation Center | 5.9 mi | ★★★★★ | 7 | 2 |
| Woodlands Place Rehabilitation Suites | 6.2 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.